What is the procedure for appealing a denied claim?

When a claim is denied by Group Health Cooperative, the first step in the appeals process typically involves reviewing the denial notice to understand the reason behind the decision. The notice usually provides specific information about why the claim was denied, including any relevant policy provisions. It is advisable for the member to gather any necessary documentation that supports the claim, such as invoices, medical records, or other pertinent evidence that substantiates the need for the service or treatment that was the subject of the claim. The member should then prepare a written appeal. This appeal should clearly state the reasons why the claim should be reconsidered, referencing any specific policy details or documentation that support the case. It is also important to include the claim number, the member's identification information, and any additional contact information in the appeal letter. Once the appeal letter is ready, it can be submitted according to the procedures outlined in the denial notice. This may involve sending the appeal via mail, fax, or an online submission portal, depending on the policies of Group Health Cooperative. It is essential to adhere to any specified timelines for submitting an appeal to ensure that the case is considered. After the appeal is submitted, the member should receive a response within a certain time frame, as dictated by the policies of the cooperative. If the appeal is denied again, the notice will typically explain the next course of action, including whether further appeals can be made. For the most accurate and detailed guidance, members are encouraged to consult the current Group Health Cooperative web page, where they can find the specific procedures and any changes that may have occurred.