(Insurance Company/HMO)
(Date)
XXXX XXXXX
XXXX XXXX XXXXX
XXX XXXXX, XX XXXXX
Member Name:
Member Number:
Provider Name:
Service: Midface Reconstruction and Oral Surgical Splint
Claim Number: XXXXXXXXXXXX. XXXXXXXXXXXX
Dear XXXX:
Thank you for your patience and cooperation during our review process. This letter will serve as a follow-up to your conversation with XXXXXXX XXXXX, Grievance Coordinator, on January 21, 2002, and is sent to you in reference to the XXX Grievance Committee meeting of December 20, 2001 and January 8, 2002.
The Committee thoroughly reviewed all of the comments, medical records and correspondence regarding your grievance. After careful consideration, the Committee tabled and postponed rendering a decision to request additional information.
Consequently, an XXX administrative decision has been made to approve the service request, Reconstruction Midface Piece, as originally requested on referral number XXXXXXXXX. XXX administration has authorized a one-time exception for the approval of the above noted procedure, noting that the procedure requested by Dr. XXXX XXXXXX is not a covered benefit by XXX. Please be advised that this is a one-time administrative exception on this service only and does not apply to other present or future services or claims whatsoever. HPN is not setting precedence with the approval of this one service only and future claims and or services are subject to the terms, agreements, conditions and exclusions of your Evidence of Coverage (EOC).
As discussed with XXXXXXX XXXXX, the above listed service has been approved and the system is currently being updated to reflect the authorization. A corrected letter of Prior Authorization from XXX's Utilization Management will be forthcoming to both you and your provider. Please remember it is the members' responsibility to pay any applicable co-payments, co-insurance and or calendar year deductible (CYD), when applicable and as outlined in your Evidence of Coverage and Schedule of Benefits.
Again, thank you for allowing the Customer Response and Resolution Department the opportunity to assist you, a valued XXX member.
If you have any questions, please call Member Services at (XXX) XXX-XXXX Monday - Friday, 8 a.m. - 5 p.m., or you may contact me directly at (XXX) XXX-XXXX.. If you are outside the XXX XXXX area, please call our toll-free number (800) XXX-XXXX.
Sincerely,
Department Manager
Customer Response and Resolution
cc: Doctor
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This cleftAdvocate page was last updated March 25, 2014
"Approval" Letter? Hmmm...
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a program of ameriface
