Appeals Processes

You have the right to request an appeal

HealthSpan has defined procedures for you to appeal denials issued as a result of our review process, whether it be due to the absence of a benefit, benefit limitations or exhaustions, or medical appropriateness. All requests for services that are denied based on medical appropriateness are determined by a board certified physician. The notice of denial will inform you of the reason for the denial and your rights to an appeal.

If you disagree with the decision, you may appeal the denial through the Appeals Unit. HealthSpan’s internal appeals process includes one level of appeal. If HealthSpan continues to deny your request, you may request a review from an external source at no cost to you. The appeal denial notice will provide you with information that you will need to initiate an external review. The appeals coordinator will facilitate the external review process by arranging the evaluation, forwarding pertinent information, and communicating with you.

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive by contacting Customer Relations at 216.621.7100.  Representatives will help determine how your concern should be handled — as a grievance or an appeal.

We will respond to your concerns as quickly as possible through our appeals process, which is detailed below and also in your Evidence of Coverage. More details on appeals and grievance requests are provided on the Appeal or Grievance Request Form* (pdf).

If you name someone to act on your behalf as your appointed representative, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative* (pdf).  Complete the appointed representative form and return to HealthSpan.

Filing an appeal

To assist you with filing an appeal or grievance, please feel free to complete this form and fax or mail to:

HealthSpan Appeals Unit
PO Box 93764
Cleveland, Ohio 44101-5764
Fax #: 1-216-635-4453

^{Note: This form is not required; however, all appeal/grievance requests must include the appropriate signatures.}

If you are on Medicare

If you are a Medicare beneficiary who received a denial for services other than Part D prescription drug benefits, the Appeals Unit will automatically forward the denial to the Medicare’s Independent Review Entity.