Step-by-step process for Level 2 appeal
A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the health plan.
Step 1 – appeal review by The Independent Review Organization
For medical coverage, if you had a "fast appeal" at Level 1, you will also have a "fast appeal" at Level 2.
For drug coverage, if your health requires it, you need to ask for a "fast appeal." The Independent Review Organization needs to agree to give you a "fast appeal."
The review organization must give you an answer to your Level 2 Fast Appeal within 72 hours of when it receives your appeal.
For medical coverage, if you had a "standard appeal" at Level 1, you will also have a "standard appeal" at Level 2.
For medical services, the review organization must give you an answer to your Level 2 Standard Appeal within 30 calendar days of when it receives your appeal. However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days for both time frames.
For drugs, if you don't ask for a "fast appeal," you will have a "standard appeal." The review organization must give you an answer to your Level 2 Standard Appeal within 7 calendar days of when it receives your appeal.
Step 2 – The Independent Review Organization gives you their answer
If the review organization says yes to part or all of what you requested, we will do the following:
For medical coverage:
We must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization.
For drug coverage:
- If the request is for prescription coverage, we must provide the drug coverage that the review organization approved within 24 hours after we receive the review organization's decision.
- If the request is to pay you back for a drug you already bought, we are required to reimburse you within 30 calendar days after we receive the review organization's decision.
If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”)
Step 3 – Further appeals (Levels 3, 4, and 5)
If you disagree with the Independent Review Organization's decision, you may be able to continue the appeal process. There are three additional levels in the appeals process after Level 2. If your Level 2 Appeal is turned down and your case meets the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal.
There is a certain dollar value that must be in dispute to continue with the appeals process. For example, to continue an appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. The written notice you get from the Independent Review Organization will tell you how to determine the minimum dollar amount to continue the appeals process.
Level 3 Appeal
A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an Administrative Law Judge.
Level 4 Appeal
The Appeals Council will review your appeal and give you an answer. The Appeals Council works for the Federal government.
Level 5 Appeal
A judge at the Federal District Court will review your appeal.
For further information on appeals, please refer to the Evidence of Coverage (EOC) Chapter 9. For appeals for Hospital discharge dates, covering other services like skilled nursing, outpatient services, and home health care, please refer to Evidence of Coverage Chapter 9, sections 7-10, or call Blue Shield of California Promise Health Plan Member Services at (800) 544-0088 [TTY: 711].
You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Member Services at (800) 544-0088 [TTY: 711], 8 a.m. – 8 p.m., seven days a week, from October 1 through March 31, and Monday through Friday, from April 1 through September 30.