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Notice of Right to Appeal and External Review

Right to appeal

If you disagree with the denial or partial denial of your claim or think this determination was made in error, you are entitled to a full and fair review of your claim by individuals associated with us, but who were not involved in making the initial denial of your claim.  You may provide us with additional information and you may request or receive copies of information that pertains to your claim.  You or your authorized or personal representative may file an appeal by submitting a written request for review within 180 days of the date of this notice.  Your request should include the date of your request, your printed name and address (and name and address of any authorized representative), the identification number and claim number from this Explanation of Health Care Benefits, the date of service, and any additional information you wish to provide.

Send your request to:

Wellmark Health Plan of Iowa, Inc.
Special Inquiries, Station 5W189
PO Box 9232
Des Moines, IA  50306-9232.

We will review our decision and provide you with a written reply.

External review

If we continue to deny the claim after review or if you do not receive a decision within 30 days, and our decision involved the medical necessity, appropriateness, health care setting, level of care, or effectiveness of health care service, or our decision was based on a determination that the service is investigational or experimental, you may have a right to have our decision reviewed by independent health care professionals who have no association with us.  You must first exhaust the internal appeal described above.  External review is not available in all cases.  If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review without exhausting the internal appeal.

For additional information or to determine if these review rights apply to your plan, please refer to your benefits plan document or contact us at the customer service number shown on the following page.

Other resources

For assistance in understanding your appeal rights, you can also contact the Employee Benefits Security Administration at 866-444-EBSA (3272) or the Iowa Insurance Division, 601 Locust St., 4th Floor, Des Moines, IA 50309-3738, 877-955-1212. If the decision on review is an adverse benefit determination and if you have employer group coverage subject to the Employee Retirement Income Security Act of 1974 (ERISA), you have the right to bring a civil action under Section 502(a) of ERISA.