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APPEALS & GRIEVANCES FOR STATE, EDUCATION, LOCAL GOVERNMENT AND GROUP PLAN MEMBERS

Member Appeals and Grievance Procedures

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).

Appeals and Grievances

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.  

Timeframe for Resolving Appeals and Grievances

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.

Levels of Review

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.

Who May File an Appeal or Grievance

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.

For example:
"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.

How to Access the Appeals and Grievances Process

Contact GlobalHealth Customer Care at (877) 280-5600, 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 (405) 280-5600 (local), (877) 280-5600 (toll-free) or 711 (TTY), Monday-Friday, from 9:00AM-5:00PM. Submit your written statement to: GlobalHealth, Appeals and Grievances Department, P.O. Box 2393, Oklahoma City, Oklahoma, 73101-2393.

You may send the information through the mail or through your MyGlobal™ account.

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.

What is an exception?

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.

How do I ask for an exception?

Start by calling, writing or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the exception process through MyGlobal™

Phone:
(877) 280-5600 (TTY users call 711)
Monday – Friday, 9:00 a.m. – 5:00 p.m. Central Time

Mail:
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.

DISPUTED CLAIMS & GRIEVANCES FOR FEDERAL EMPLOYEES

Member Disputed Claim and Grievance Procedures

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, disputes, and coverage determinations (including exceptions).

Disputed Claims and Grievances

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes.

A disputed claim is a request for reconsideration of a decision to deny services or payment of services (i.e., a denied benefit, claim or service). Disputed claims will follow the standard or expedited process. An expedited disputed claim is a request to change an adverse determination for urgent care where the standard process could seriously jeopardize the life or health of the member or the member's ability to regain maximum function. Expedited disputed claims apply only to decisions to deny services.

A grievance is an oral or written expression of dissatisfaction or complaint. Grievances may consist of quality of care and/or quality of service issues, such as office waiting times, physician behavior or adequacy of facilities. GlobalHealth will attempt to resolve any complaint that the member might have. We encourage the informal resolution of complaints. However, if the complaint cannot be resolved in this manner, a more formal Member Grievance Procedure is available.

Timeframe for Resolving Disputed Claims and Grievances

The following timeframe applies to each disputed claim and grievance:

• Members must file their disputed claims within 180 days after the denial notification.
• Standard disputed claims (denial of service) must be resolved within 30 days of receipt by GlobalHealth.
• Expedited disputed claims (denial of service) must be resolved within 72 hours of receipt by GlobalHealth.
• Standard disputed claims (denial of payment of a service already rendered) must be resolved within 30 days of receipt by GlobalHealth.
• Grievances must be resolved within 30 days of receipt by GlobalHealth.
• The timeframe regarding GlobalHealth's resolution may be extended upon mutual agreement by the member.
  
  

Who May File a Disputed Claim or a Grievance

A grievance or disputed claim can be filed by a member or someone else appointed by the member to file the disputed claim on his or her behalf. To appoint someone else as your representative, please provide the following:

• Provide GlobalHealth a statement that appoints him/her to act on your behalf.

For example:
"I [member name] appoint [name of representative] to act as my representative in requesting a disputed claim from GlobalHealth regarding ________________________ (insert the type of denial or discontinuation of service)."

• Include the member's GlobalHealth Identification 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 disputed claim may be filed by a physician on behalf of the member without submitting a member representative form.

How to Access the Disputed Claim and Grievances Process

Contact GlobalHealth Customer Care at (877) 280-2989, or you may 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 (405) 280-2989 (local), (877) 280-2989 (toll-free) or 711 (TTY), Monday-Friday, from 9:00AM-5:00PM. Submit your written statement to: GlobalHealth, Disputed Claims sand Grievances Department, P.O. Box 2393, Oklahoma City, Oklahoma, 73101-2393.

You may send the information through the mail or through your MyGlobal™ account.

GlobalHealth will send a written acknowledgment of the receipt of your disputed claim or grievance and an explanation of the review procedure within five (5) calendar days of receipt.

Levels of Review

An additional level of review through the Office of Personnel Management (OPM) is available to members that have exhausted the internal disputed claims process with GlobalHealth. Your request for external review must be submitted in writing within:

• 3 months (90 days) after receipt of this notice; or
• 120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at:

United States Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
FEHB 3
1900 E Street, NW
Washington, DC 20415-3630

For standard external reviews, a decision will be made within 60 days of receiving your request. 

If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our decision was based on a determination that the service or treatment is experimental or investigational, you also may be entitled to file a request for expedited external review of our denial if your treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated. To request an expedited review, contact OPM’s Health Insurance 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time. 

What is an exception?

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 dispute 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.

How do I ask for an exception?

Start by calling, writing or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the exception process through your MyGlobal™ account.

Phone:
(877) 280-5600 (TTY users call 711)
Monday – Friday, 9:00 a.m. – 5:00 p.m. Central Time

Mail:
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 dispute.