Legal

Grievance and appeal procedures for Arizona

Welcome to the Superior Vision Plan underwritten by National Guardian Life Insurance Company (NGLIC). NGLIC contracts with Superior Vision Services, Inc. to provide access to their network of vision care providers. The Superior Vision Plan is a vision care program designed to offer a high-level of vision care to you and your family. We do this through a broad-based provider network comprised primarily of board-certified ophthalmologists (MD) complemented by optometrists (OD), opticians, and optical companies who are responsible for delivering quality services.

Superior Vision Plan offers one of the largest networks of vision care providers. If you are looking for an eye doctor or need assistance in choosing one nearest you, you may call the customer service toll-free telephone number shown on your ID card, or visit the Superior Vision Services website: superiorvision.com.

Please read this notice carefully. It contains important information about your vision plan and your right to contest a claim decision or file a Grievance.

Definitions

“Covered Person” means an eligible employee or his or her eligible dependents covered under the Superior Vision Plan. The term Covered Person includes a representative duly authorized in writing to submit a Grievance on behalf of the Covered Person.

“Emergency Medical Condition” means the sudden, and at the time, unexpected onset of a health condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

1. Placing the member’s health in serious jeopardy;
2. Serious impairment to any of the member’s bodily functions; or
3. Serious dysfunction of any of the member’s bodily organs or parts.

“Grievance” means a written complaint submitted by or on behalf of Covered Person regarding:

1. The availability, delivery, or quality of vision care services;
2. Claims payment, handling, or reimbursement for vision care services; or
3. Any other matter pertaining to the contractual relationship between a Covered Person and the Insurer.

“Insurer” means the insurance carrier underwriting the Superior Vision Plan.

“Urgent” means non-life or limb threatening, or vision acuity is affected prior Vision Plan provides wellness benefits for routine eye examinations and eyewear in accordance with the terms and conditions of the Master Policy. It does not cover treatment of a medical or ophthalmologic condition. Contact your Medical Plan if you have questions concerning coverage for treatment of a medical or ophthalmologic condition.

If you call seeking services for an Emergency or Urgent Medical Condition, or an immediate situation a customer service representative will direct you as follows:

1. For “Emergency Medical Conditions” situations, members are directed to contact their local EMC, or call 911.
2. For “Urgent” medical conditions, members are instructed to contact their Medical Plan or Provider or local UCC.
3. For immediate situations where a member may have lost or damaged his or her contact lenses or eyeglasses and the member is out-of town, a customer service representative may facilitate directing the member to a contracted provider in the area.

Resolving claim problems or concerns

If you have a problem or concern, you should first call the Superior Vision Plan customer service toll free number shown on your ID card. Most problems or concerns can be handled with a single phone call. A customer service representative will work with you to help you understand your coverage or resolve your problem or concern as quickly as possible.

Customer service representatives are trained to respond to calls quickly, resolve problems promptly and exercise sensitivity.

When resolving a problem or concern, we will consider all aspects of the particular case, including the terms of your insurance certificate, the policy and procedures that support your insurance coverage, the provider’s input, and your understanding and expectations of your coverage. We will use every opportunity to be reasonable in find a solution that makes sense for all parties. We will follow our standard business practices guidelines when resolving your problem or concern.

Who to contact

If you disagree with the decision or explanation given to you by the customer service representative or if you have a complaint about any other issue regarding your insurance you may request a grievance review.

To request a formal grievance review you have three options.

1. The preferred option is to send your Grievance in writing (company specific form is not required) to:
   “Grievances” Superior Vision Services, Inc.,
   Administrator for NGLIC
   881 Elkridge Landing Road
   Suite 300
   Linthicum Heights, MD 21090
2. If you choose you may fax it to us at: 916-852-2290, or
3. You may send your Grievance by email to [email protected] or through our secure website member portal.

We will let you know that your request was received by sending you a confirmation in writing or by email (if address is provider) within 15 business days.

Requesting a grievance review

Any person making an oral complaint will be instructed to document his or her concerns and to submit a formal Grievance in writing to us at the address above.

Your request for a grievance review should include:

• The name and identification number of the member asking for the review;
• A description of the problem;
• All relevant dates;
• Names of health care providers or administrative staff involved; and
• Details of the attempt that was made to resolve the problem.

A Grievance may be submitted to us by or on behalf of a Covered Person within one year of the date of treatment, event or circumstance giving rise to the Grievance, such as the date of the claim denial.

Written resolution of internal grievance review

Once your request is received, we will research the case in detail, ask for more information as needed and let you know, in writing, of the decision or the outcome of the investigation into your case.

If deemed necessary and appropriate, your grievance may be forwarded to our CQI program.

As a participant in the plan you are entitled to certain rights and protections under the Employee Retirement Income Act of 1974 (ERISA). ERISA provides that if your claim for a welfare benefit is denied, in whole or in part, you have the right to know why this was done, to obtain copies of all documents relating to the decision without charge, and to contest any denial, all within certain time schedules. If you have questions about your rights and responsibilities under ERISA you may contact the Benefits Security Administration, US Department of Labor, 200 Constitution Avenue NW, Washington DC 20210.

Written resolution of the grievance review will include the specific information considered and an explanation of the basis for the decision. We will provide you and the provider furnishing the vision care services, if applicable, a written decision within thirty (30) calendar days following the request for a review.

The time frame to complete our review may be extended if we and you agree additional time is required to fully investigate and respond to the Grievance.

Grievance review / appeal decision

Denial upheld – If we continue to agree that the covered services or claim for a covered service should have been denied, the complainant will receive a written notice of that decision.

Denial Reversed – If we agree that the covered services should have been provided, or that the claim should have been paid we will authorize the service or pay the claim.

Grievance records

We will maintain a record of each Grievance, including the response for each grievance review, for up to seven years.

As an Arizona member participant, any member who is denied a covered service or whose claim for a service is denied may pursue the applicable review process.

Formal appeal

1. After any applicable consideration Superior Vision denies the member’s request for covered service, the member may appeal that adverse decision. The member shall mail a written appeal to Superior Vision within sixty (60) days after receipt of the adverse decision. In the event of a denial of a claim for a service that has already been provided, the member may request, either orally or in writing, an informal reconsideration by notifying Superior Vision within two (2) years after the receipt of the notice of denial.
2. Superior Vision shall mail a written acknowledgement to the member and the member’s treating provider within five (5) business days after Superior Vision receives the formal appeal.
3. The member or the member’s treating provider shall submit to Superior Vision with the written formal appeal, any material justification or documentation to support the member’s request for the service or claim for a service.
4. If the member’s compliant is an issue of medical necessity under the coverage document and not whether the service is covered, a provider, physician, or other health care professional who is licensed pursuant to title 32 of the Arizona revised statutes, chapter 7,8,11,13,14,16,17,19 19.1, or 29 or an out of state provider physician or other health care professional who is licensed pursuant to title 32 of the revised Arizona statutes, chapter 7,8,11,13,14,16,17,19 19.1, or 29 or an out of state provider, physician or other health care professional who is licensed in another state and who is not licensed in Arizona and who typically manages the medical condition under appeal shall review the appeal and render a decision based on the utilization review plan adopted by Superior Vision. Pursuant to the requirements of this, Superior Vision shall select the provider physician or other health care professional who shall review the appeal and render the decision.
5. Except as provided in section F. (below), Superior Vision has:
   1.With respect to adverse decisions relating to services that have not been provided, up to thirty (30) days after receipt of the written appeal to notify the member in writing of Superior Vision’s decision and the criteria used and the clinical reasons for that decision. 2.With respect to denials relating to claims that have already been provided, up to sixty (60) days after receipt of the written appeal to notify the member in writing of Superior Vision’s decision and the criteria used and the clinical reasons for that decision.
6. At any time during the formal appeal process Superior Vision may request an external independent review process. If Superior Vision initiates the external independent review process, Superior Vision does not have to comply with section E. (above).
7. If at the conclusion of the formal appeal process Superior Vision denies the appeal and Superior Vision does not initiate the external independent review process, Superior Vision shall provide the member with notice of option to proceed to an external independent review.
8. If Superior Vision concludes that the covered service should be provided or the claim for a covered service shall be paid, the health insurer (NGLIC) is bound by Superior Vision’s decision.

External independent review

1. If Superior Vision denies the member’s request for a covered service or claim for a covered service at Formal Appeal level, the member may initiate an external independent review.
2. Except as provided in section K. (below) within sixty (60) days after the member receives written notice by Superior Vision of the adverse decision, if the member decides to initiate an external independent review, the member shall mail to Superior Vision a written request for an external independent review, including any material justification or documentation to support the member’s request for the covered service or claim for a covered service.
3. Except as provided in section K. (below), within five (5) business days after Superior Vision receives a request for an external independent review from the member pursuant to section B and G, or if Superior Vision initiates an external independent review, Superior Vision shall: 1.Mail a written acknowledgement to the director, member and the member’s provider and the health care insurer. 2.Forward to the director the request for review, the terms of the agreement in the member’s policy, evidence of coverage or a similar document and all medical records and supporting documentation used to render the decision pertaining to the member’s case, a summary description of the applicable issues including a statement of Superior Vision’s decision, the criteria used and clinical reasons for that decision, the relevant portions of Superior Vision’s review plan and the name and credentials of the licensed health care provider who reviewed the case.
4. Except as provided in section K, within five (5) days after the director receives all of the information prescribed in section C, the director shall choose and independent review organization and forward to the organization all of the information required by section C.
5. Except as provided in section C (above) for cases involving an issue of medical necessity under the coverage document, within twenty-one (21) days after the date of receiving a case for independent review from the director, the independent review organization shall evaluate and analyze the case and, based on all information required under section C (above) render a decision that is consistent with the utilization review plan on whether or not the service or claim for the service is medically necessary and send the decision to the director. Within five (5) business days after receiving a notice of decision from the independent review organization, the director shall mail a notice of the decision to Superior Vision, the health insurer, the member and the member’s treating provider. The decision by the independent review organization is a final administrative decision pursuant to title 41 of the Arizona revised statutes, chapter 6 article 10 and is the subject to judicial review pursuant to title 12, chapter 7, article 6, article 10 and is subject to judicial review pursuant to title 12, chapter 7, article 6. The health care insurer shall provide any service or pay any claim determined to be covered and medically necessary by the independent review organization for the case under review regardless of whether the judicial review is sought.
6. Except as provided in section K of this section, for cases involving an issue of coverage, within fifteen (15) business days after receipt of all of the information prescribed in section C (above) from Superior Vision, the director shall determine if the service or claim is or is not covered and if the adverse decision conforms to Superior Vision’s utilization review plan and this article and shall mail a notice of determination to Superior Vision, the health insurer, the member and the member’s treating provider.
7. If the director finds that the case involves a medical issue or is unable to determine issues of coverage, the director shall submit the member’s case to the external independent review organization in accordance with section E (above) or K (below).
8. After a decision is made pursuant to sections E, F, G or K, the reconsideration, appeal and administrative processes are completed and the department’s role is ended, except:
   1. To transmit, when necessary, a record of the proceedings to superior court or to the office of administrative hearings. 2. To issue a final administrative decision pursuant to section 41-1092.08.I. Except as provided in section K (below) on written request by the independent review organization, the member or Superior Vision, the director may extend the twenty-one (21) day time period prescribed in section E (above) for up to an additional thirty (30) days if the requesting party demonstrates good cause for extension.
9. A decision made by the director or an independent review organization pursuant to this section is admissible in proceedings involving a health care insurer or Superior Vision.
10. (20-2535 Expedited medical review; expedited appeal) – not applicable.
11. Notwithstanding title 41 of the Arizona revised statutes, chapter 6, article 10 and section 12-908, if a party to a decision issued under this section seeks further administrative review, the department shall not be a party to the action unless the department files a motion to intervene in the action.
12. The independent review organization, the director or the office of administrative hearings may not order the health care insurer to provide a service or to pay a claim for a benefit for a service that is excluded from coverage by the contract.
13. The health care insurer shall provide any service or pay any claim determined in a final administrative decision to be covered and medically necessary for the case under review regardless of whether judicial review is sought. Any proceedings before the office of administrative proceedings that involve an expedited external independent review and that are subject to section K (above) shall be promptly instituted and completed.

Grievance records

We will maintain a record of each Grievance, including the response for each grievance review, for up to seven (7) years.

Replacement notice

You may obtain a replacement notice outlining this grievance and appeals process by contacting Superior Vision Services Customer Service Department at (800) 507-3800. Upon request, your provider shall we will sent a copy of this grievance and appeals notice within five (5) business days after the date the appeal is initiated pursuant to an expedited medical review, expedited appeal, informal reconsideration and/or formal appeal.