Appeals

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    What is an appeal?

    An appeal is a request you may file when you disagree with a benefit determination including a rescission. You may appeal the decision within 180 days from receipt of the adverse benefit determination. 

    More Info: 
    Details on the formal appeals process can be found in your policy document in Section 10 – Complaints, Grievances and Appeals. Find my Policy Document

    Need help?
    Contact customer service 800-299-6080

     

    Determine if your request qualifies.

    To determine if your request qualifies as an urgent treatment request review Section 10 – Complaints, Grievances, and Appeals of your policy document.

    Find your policy in your member portal.

    Submit via Phone

    Telephone: 833-412-4144 

    Submit online

    Grievance or Complaint

    A grievance involves a complaint of unfair treatment or quality of care received from a provider’s staff. A complaint involves a communication from the Covered Person expressing discontent or dissatisfaction with services.

    More Info: 
    Details on the formal appeals process can be found in your policy document in Section 10 – Complaints, Grievances and Appeals.

    Submit via mail

    If you think Mountain Health CO-OP has made a wrong decision on a service, supply, or drug you have received, you can contact us in writing or by phone at:

    HealthComp UM Department, PO Box 45018,Fresno, CA 93718-5018 

     

    Submit via Fax

    Telephone: 559-243-7012

    Submit online

    External Review for Health Claim Denials

    A Claimant (or someone acting on the Claimant’s behalf) may request an independent external review of an adverse benefit determination within 120 days after notice of an adverse benefit determination. In most cases, before filing an external review, you must first exhaust your internal grievance and appeal rights. 

    Submit a request an external review via mail or phone

    The request shall be made in duplicate and include a fee of fifteen dollars ($15.00) payable by check or money order payable to: The Office of the Wyoming State Treasurer. 

    The fee may be waived for a member whose income is at or below the current federal poverty level guidelines and who files a financial hardship application available upon request from the Wyoming Insurance Department.