Utilization Management/Provider Local and Alternative Dispute Resolution

Utilization Management Provider Local and Alternative Dispute Resolution Policy

Attachment: Adequate Notice of Adverse Benefit Determination (Uninsured or Underinsured

Attachment: Administrative Local Dispute Resolution Review Determination Form (Uninsured or Underinsured

Attachment: Advance Notice of Adverse Benefit Determination Form (Uninsured or Underinsured)

Attachment: Appointment of Representative Form

Attachment: Enrollee Agreement for Request for Additional Information Form (Uninsured or UnderInsured)

Attachment: IRO Physician Reviewer Documentation Form

Attachment: IRO Referral Review Request Form

Attachment: Local Dispute Resolution Review Request Form (Uninsured or Under Insured

Attachment: Notice of Administrative Denial Form (Uninsured or UnderInsured)

Attachment: Notice of Local Dispute Resolution Approval Form (Uninsured or Underinsured)

Attachment: Notice of Local Dispute Resolution Denial Form (Uninsured or Underinsured)

Attachment: Notice of Receipt of Local Dispute Review Request

Attachment: Physician Letter (Uninsured or Under Insured)

Attachment: Post-Service Provider Local and Alternative Dispute Resolution Procedures (Uninsured or Underinsured

Attachment: Pre-Service Provider Local and Alternative Dispute Resolution Procedures (Uninsured or Underinsured)

Attachment: Request for Additional Information (Uninsured or UnderInsured)