Page 72

Effective Date:

Approval Date: 72

UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Decision maker Health plan's medical director or physician advisor when medical review is needed or appropriate. When the issue requires an administrative the appropriate department makes the decision. Persons involved in the initial determination may not review the appeal. Wellmark Blue Cross and Blue Shield Enrollee Appeal Committee Delta Dental Appeal Committee. Time frame for decision Within 30 calendar days of receipt of complaint with details of the decisions and further appeal process available to Enrollee, should decision not be in Enrollee's favor. The written decision may be extended by ten business days to obtain documentation records necessary to resolve the case and the delay is in the interest of the Enrollee. 30 calendar days from receipt of form, if no additional information is needed. If additional information is not received in time allowed, Wellmark will make a decision. Within 30 days of receiving the request. Notification of decision Written letter to all parties involved. Written letter to all parties involved. . Written letter to all parties involved. Expedited Appeal Requested to accommodate the urgency of the situation when the standard appeal process will cause delay in the rendering of health care that would be life threatening or severe enough to seriously jeopardize the member's health and/or ability to regain maximum function. May be requested anytime there is denial in utilization management and the situation is urgent. May be requested if the situation is urgent. Who can file a complaint or an appeal Enrollee or physician contacts UHC verbally or in writing with request for expedited appeal. An enrollee's physician, family member or other individual may act as the Enrollee's representative to assist in filing an appeal on behalf of the Enrollee.

Enrollee, physician or hospital The Enrollee, a representative of the Enrollee, or the dentist. Decision Maker Medical director or physician advisor Medical director or physician advisor Dental director or dental consultant.