Appeals Process

You, or someone acting on your behalf or the provider of record, have the right to appeal any decision not to provide or pay for a service or treatment in whole or in part by following the Appeal Process.

1. What is an appeal?

An appeal is a request to reconsider a decision determined by the Utilization Review Agent. You can appeal the Adverse Benefit Determination if NPUA: 

  • Is denying coverage for care you think should be covered. 
  • Provides a partial approval for a covered service. 

2. When do I have the right to ask for an appeal? 

You, your authorized designee, or your provider must send NPUA a request, orally or in writing, to reconsider the initial determination no later than 180 days after the date of the initial decision letter.  

3. How do I request an appeal?

Please follow the below steps to request an appeal: 

  • Written Appeal: To submit a written appeal, mail or fax the written appeal to the following: National Programmatic Utilization Alliance LLC, Utilization Review Unit, 1359 Broadway, 2nd Floor, New York, NY 10018 or fax 646-768-9719.   
  • Oral Appeal: To file an oral appeal, call the following toll-free number: 1-866-960-3596.  
  • Authorized Representative: If you are authorizing someone to file on your behalf, you will need to return the plan Authorized Representative form.  

Within 3 working days of receipt of the appeal, we will send the appealing party a letter acknowledging the date that we received the appeal and a list of documents that we may need for the appeal. If the appeal is oral, we will send the appealing party a one-page appeal form. The appealing party does not have to return the appeal form, but we encourage its return because the form will help us resolve the appeal. 

4. Can someone help me file an appeal?

For help or more information on how to file an appeal, call the following toll-free number: 1-866-960-3596. Also, depending on which state you live in, your state’s department of insurance may have an assistance program established to assist you with internal claims, appeals, and external review processes. 

5. What are the timeframes for NPUA’s appeals process?

If your Plan has one level of appeal, the deadlines to resolve the appeal and send a written decision to you or someone acting on your behalf and the provider of record are:  

  • Standard Appeal (an appeal related to a service or treatment that has not yet been received): 30 calendar days from when we receive the appeal.  
  • Expedited Appeal (an appeal related to prospective, continued, or extended health care services or additional care related to an urgent situation.  Generally, an urgent situation is one in which your health, the health of your fetus or your ability to regain maximum function would be in serious jeopardy or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on the appeal of your claim.): The lesser of one working day from the date we receive the appeal or 72 hours. We may provide the determination by telephone or electronic transmission but will provide a written determination within 72 hours of receipt of the appeal. 
  • Retrospective Appeal (any appeal that is not a standard or expedited appeal): 30 calendar days after receipt of appeal.   

If we do not have all the information to make a determination on your request, determination may be delayed while we request additional information to process your appeal.  

6. Does my appeal request have to be in writing?

No. An appeal request can be submitted either orally or in writing.