What happens if my request is denied?
If services are determined to be not medically necessary, they will be denied by our Medical Director(s). HealthSpan then notifies your provider by phone. Your provider may submit new information at that time for reconsideration. This is not an appeal as defined by many health plans.
A reconsideration is the first option to get a second review of the service. The same HealthSpan physician who made the original determination will review the reconsideration. Any change in the decision would be based on the new data provided.
If you wish to appeal, you are responsible for submitting it to the administrator (TPA or insurance company) according to the rules of your plan. Contact your administrator or TPA for more information.