Request an appeal if coverage of any health care service is denied, either wholly or in part. An appeal is an internal review of an Adverse Medical Benefit Determination. You have 180 days from the date of the Adverse Benefit Determination to file an appeal.
Appoint a person of your choosing to represent you. This person is known as an Authorized Representative and can be, but does not have to be, an attorney.
Reasonable access to, and copies of, all documents, records, and information relevant to your Claim and relied upon in making the Adverse Medical Benefit Determination. This information will be made available upon request at no cost to you.
Submit written comments, documents, and other information relevant to your appeal.
Obtain the title and qualifications of the person(s) who participated in the Adverse Medical Benefit Determination, if the determination was based on medical necessity or if the Plan determined the services are/were experimental or investigational.
Request an Expedited (“Fast Track”) Appeal.
If your appeal situation is urgent, call the St. Luke’s Health Plan Appeals Coordinator at 1-833-353-0312.
Urgent is defined as a situation in which, in the opinion of a physician with knowledge of the Claimant’s medical condition, the application of the time periods for making non-urgent appeal determinations could seriously jeopardize the Claimant’s life, health, or ability to regain maximum function; or would subject the Claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the Claim.
If the Plan determines the situation is urgent, the Plan will issue an appeal determination within 72 hours of receiving the appeal request.
If the Plan determines the situation is not urgent, the Plan will issue a determination within the non-urgent appeal timeframe. Non-urgent appeal determination timeframes are as follows:
30 days if the services have not been rendered yet (Pre-Service).
60 days if the services have already been rendered (Post-Service)
You or your Authorized Representative will be notified by the Plan within 72 hours if your request for an Expedited Appeal was denied.
Expedited Appeals are only available for services denied prior to being rendered (Pre-Service) or services that are ongoing (Concurrent). If the service has already been completed (Post-Service), an Expedited Appeal review will not be granted; the Plan will issue an appeal determination within the Post-Service appeal timeframe of 60 days.
Appeal Request Forms are available by contacting Customer Service. Use of this form is not required, but it is helpful in guiding you to provide the information that is necessary and/or most helpful for us to render an appeal determination.
Appeals can be submitted in writing via mail, fax, or email using the contact information below:
Attn: Appeals Coordinator
PO Box 91010
Seattle, WA 98111
NOTE: only urgent appeals can be submitted via telephone.
St. Luke's Health Plan, Inc
Pharmacy benefit Manager
701 Morrison Knudsen Drive, 3rd Floor
Boise, ID 83712
You or your Authorized Representative must file your appeal within 180 days of the date on your Adverse Medical Benefit Determination notice. Non-urgent appeals must be submitted to the Plan in writing.
You or your Authorized Representative are encouraged to include comments, documents, records and/or other information that explains the reason you believe your Claim should be approved. St. Luke’s Health Plan will send a letter acknowledging receipt of your appeal within five (5) calendar days.
Upon receipt by the Plan, an Appeals Coordinator will prepare the documents and any applicable documentation from the Agreement for review and discussion by the St. Luke’s Health Plan’s Appeal Committee or Chief Medical Officer. The individual who made the original Adverse Medical Benefit Determination will not be involved in the internal appeal process. The committee or Chief Medical Officer will review the information and make a recommendation to St. Luke’s Health Plan to either uphold or overturn the original Adverse Medical Benefit Determination.
St. Luke’s Health Plan will notify you in writing of the decision to either uphold the original denial or overturn it within 30 calendar days of Pre-Service Claims or 60 calendar days of Post-Service Claims. If the determination is to uphold the original denial based on Medical Necessity, the letter will also include information on how to initiate the next level of appeal (External Review).
You are entitled to external review if the denial was based on medical judgment or rescission. Denials that do not involve rescission or medical judgment (i.e., denials that involve only contractual or legal interpretation without any use of medical judgment) are not eligible for external review.
External review requests can be submitted to the Plan using the same address, email address, or fax as an internal appeal request. The contact information is listed above under How to Request an Appeal. External review requests can also be submitted directly to the Idaho Department of Insurance:
You or your Authorized Representative must first submit an internal appeal and receive a final internal Adverse Medical Benefit Determination before you request external review. Your request for external review must be received within 120 days of the date indicated on your final internal Adverse Medical Benefit Determination.
St. Luke’s Health Plan will conduct a preliminary review to determine if the Claim is eligible for external review within (14) calendar days of the receipt of a request. The Plan will send you notification of its decision within one business day thereafter.
You or your Authorized Representative can request an expedited external review to occur simultaneously as an internal appeal.
St. Luke’s Health Plan will conduct a preliminary review to determine if the Claim is eligible for external review within two (2) business days of the receipt of the request. The Plan will send you notification of its decision within one business day thereafter.
This notice of the decision of eligibility for external review will include the following:
If your request is found ineligible for external review, the reason for its ineligibility;
If your request is eligible for external review but not complete, a description of any additional information or materials required to complete your request;
If your request is complete and eligible for external review, contact information for the Independent Review Organization (IRO) assigned by the Idaho Department of Insurance, and details about your right to provide additional information.
If eligible for external review, St. Luke’s Health Plan will forward your appeal, including all information and documentation considered in both the original denial and the internal appeal, as well as any additional documentation you submit, to the Idaho Department of Insurance within five (5) business days of determining the Claim is eligible for external review.
The Idaho Department of Insurance will assign an Independent Review Organization (IRO) within seven (7) business days of the receipt. The IRO consists of independent physicians or other specialists that are not associated with St. Luke’s Health Plan. If applicable, they will possess medical training specific to the services that are the subject of the appeal.
The IRO will notify you that your appeal has been received and will allow you at least ten (10) business days to submit any additional information to the IRO that you wish to be considered in reviewing your appeal. The IRO will review all information submitted, make a determination, and notify both you and St. Luke’s Health Plan of the results within forty-five (45) calendar days. Decisions regarding Urgent Care Claims are made as expeditiously as the Member’s health condition requires, but not later than 72 hours after receipt of a request.
The decision made by the IRO is the final decision of appeal. If the IRO overturns the original Adverse Medical Benefit Determination, the Appeals Coordinator will forward that decision to the appropriate party for Claim payment or, if a Pre-Service Claim, approval of the request for authorization.
If you exhaust these Claim and Appeal procedures, you have the right to file a civil action. The civil action must be filed within 180 days from the date of the written notice of St. Luke’s Health Plan’s final determination.