To verify if your employer offers Appeals, please refer to your Summary Plan document. All appeals must be submitted in writing within 180 days following the receipt of a notification of an Adverse Benefit Determination. If the appeal qualifies as an Expedited case, then the appeal request can be taken verbally. Appeals Specialists will work with appropriate staff to determine if an appeal qualifies to be expedited.
Appeals Specialists will determine if an appeal is a valid appeal by verifying that Quartz has processed the issue correctly. Valid appeals will be acknowledged within five business days by a mailed letter to the participant. The appeal will be resolved within 30 days for pre-service requests and 60 days for post service claims. Participants have the right to submit relevant testimony with the appeal.
Your provider will need your approval which can be submitted on the Appointment of Authorized Representative form.
Once a decision has been reached and if it is unfavorable for the participant, you may have the option to file a request for external review. If this is an option for your appeal, the external review rights will be given to you with the final internal determination.