Appeals Process for Base PPO Plan (70/30) and Enhanced PPO Plan (80/20)
If you have a grievance, you have the right to request that the State Health Plan or its representative review the decision through the grievance process. The grievance process is voluntary and may be requested by the member or by an authorized representative acting on the member's behalf.
First level grievance reviews must be requested in writing on the Request for Appeal or Grievance Review form within 180 days of a denial for coverage. You will be notified in written terms of the decision no later than 30 days from the date the State Health Plan or its representative received the request.
If you are dissatisfied with the first level grievance review decision, you have the right to a second level grievance review. This request must be made in writing within 180 days of the first level grievance review decision. The second level review meeting, which will be conducted by a review panel coordinated by the State Health Plan, will be held within 45 days after the State Health Plan or its representative receives a second level grievance review request. A written decision will be issued to you within five business days of the review meeting.
You have the right to a more rapid or expedited review of a denial of coverage if a delay: (i) would reasonably appear to seriously jeopardize your or your dependent's life, health or ability to regain maximum function; or (ii) in the opinion of your provider, would subject you or your dependent to severe pain that cannot be adequately managed without the requested care or treatment. An expedited review may be initiated by calling the State Health Plan Customer Services number. The decision will be communicated by phone to you and your provider no later than 72 hours after receiving the request. A written decision will be communicated within four days after receiving the request for the expedited review.
Use this form to appeal a plan decision or request a grievance review.
Note: All pharmacy appeals should use the Appeals form above.