Commercial Appeals and Grievances
Click Here for Medicare Appeals and Grievances
See below for State of Oklahoma Employees Members Appeals and Grievances
APPEALS & GRIEVANCES FOR STATE OF OKLAHOMA EMPLOYEES MEMBERS
In accordance with applicable laws, regulatory requirements, and established policies, GlobalHealth maintains effective processes to ensure timely response and resolution of member complaints. You can also find detailed information in your plan benefit documents about grievances, appeals, and coverage determinations (including exceptions).
An appeal is a request for reconsideration of a decision to deny services or payment of services (i.e., a denied benefit, claim or service). Appeals may be either standard or expedited. A standard appeal follows normal processing timeframes. An expedited appeal involves a request to appeal an adverse determination where the standard appeal process could seriously jeopardize the life or health of the member or the member's ability to regain maximum function. Expedited appeals apply only to decisions to deny services.
A grievance is an oral or written expression of dissatisfaction or complaint. Grievances may include quality of care concerns and/or quality of service issues such as office waiting times, physician behavior or adequacy of facilities. Regardless of the issue, GlobalHealth will attempt to resolve any complaint a member may have.
The following timeframe applies to each appeal and grievance:
- Members must file their appeals within 180 days after receiving the denial notification.
- Standard appeals (denial of service) are resolved within 30 days of receipt by GlobalHealth.
- Expedited appeals (denial of service) are resolved within 72 hours of receipt by GlobalHealth.
- Standard appeals (denial of payment of a service already rendered) are resolved within 60 days of receipt by GlobalHealth.
- Grievances are resolved within 30 days of receipt by GlobalHealth.
- The timeframe for resolution may be extended upon mutual agreement by GlobalHealth and the member.
An additional level of appeal through the Oklahoma Department of Insurance is available to members that have exhausted the internal appeals process with GlobalHealth. Click here for more information on the External Appeal process under the Consumer Assistance tab.
A grievance or appeal can be filed by a member or someone else appointed by the member to file the appeal on his or her behalf. To appoint someone else as your representative, the member should provide one of the following:
- A signed Appointment of Representative form.
- A written statement from you that appoints the individual to act on your behalf.
"I [member name] appoint [name of representative] to act as my personal representative in requesting an appeal from GlobalHealth regarding ________________________ (insert the type of denial or discontinuation of service and date)."
- Include the member's GlobalHealth ID number.
- Include the appointed representative's relationship to the member.
- Include both the member and the appointed representative’s address and telephone number.
- Both the member and the representative must sign and date the statement.
An expedited appeal may be filed by a physician on behalf of the member without submitting a member representative form.
Contact GlobalHealth Customer Care at (877) 280-5600 (TTY users call 711), or submit a written statement containing the following information:
- Your name and address
- Your GlobalHealth membership ID #
- Provider of service
- Copy of claims (if applicable)
- A complete and accurate explanation of your appeal or grievance and the resolution you are seeking.
Forms are available upon request by calling GlobalHealth Customer Care at (877) 280-5600 (toll-free) or 711 (TTY), Monday-Friday, from 9:00AM-5:00PM. Submit your written statement to:
C/O Appeals and Grievances Department
P.O. Box 2393, Oklahoma City
GlobalHealth will send a written acknowledgment of the receipt of your appeal or grievance and an explanation of the review procedure within five (5) calendar days of receipt.
If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception". If we turn down your request for an exception, you can appeal our decision.
When you request an exception, your doctor or other prescriber will be required to provide supporting documentation of medical necessity. We will then consider your request.
Typically, our Drug Formulary includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.
If an exception is approved, your non-preferred drug copay will apply. For a list of potential alternatives on your plan’s formulary, click here.
Start by calling, writing or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this.
(877) 280-5600 (TTY users call 711)
Monday – Friday, 9:00 a.m. – 5:00 p.m. Central Time
GlobalHealth, Pharmacy Exceptions Department
P.O. Box 2393
Oklahoma City, Oklahoma, 73101-2393
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (urgent) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
If we approve your request, depending on the drug, most formulary exceptions are granted for a minimum of one year beginning on the date the formulary exception was originally approved.
If the exception is denied, you have the right to request an appeal.