Multi-Step Appeal Review Process

[Christine Roberts]

Self funded group health plan processes claims and appeals in-house; claim appeal process is three step: appeal is first reviewed by claim manager, then by committee consisting of senior benefit managers, then by president of company.

Claim manager and committee can deny claims before passing them on to the next level. However no subsequent appeal can be made.

This is a single-level appeal process, yes? My understanding is that a two-step appeal process requires a complete second shot at claim approval, following one unsuccessful appeal.

And is it appropriate (necessary) to spell out the three-step process in the SPD?