What can be appealed?
- Authorization or claim denied as a non-covered benefit
- Authorization or claim denied as not medically necessary
- Point of Service (POS) charges can only be appealed when due to an emergency
- Payment reduction for no authorization can only be appealed when due to an emergency
What cannot be appealed?
- Charges denied as duplicate, included in allowed amount, incidental or mutually exclusive
- Charges denied for insufficient information or requested information not received
- Allowed amount disputes
- POS disputes (except when due to an emergency)
- Authorization or referral redirected to a network provider or military hospital or clinic
