Appeals Process

State Health Benefits Program

The State Health Benefits Program has a specific appeals procedure for retirees in the self-funded plans administered by Anthem Blue Cross Blue Shield (Advantage 65, Advantage 65 – Medical Only, Option I, Option II) to review the denial or payment of a claim.

  • You can request a review within 60 days of Anthem’s denial of your initial claim
  • If you are not satisfied with the results of the review, you can pursue two levels of appeals with the Claims Administrator
  • A final appeal can be requested by writing to the Commonwealth of Virginia Department of Human Resources Management if you are still not satisfied with Anthem’s decision
  • In situations requiring immediate medical care, Anthem provides a separate expedited emergency appeals process; they will provide resolution within one business day of receipt of all information

Process

Review and Two Levels of Appeals Through Anthem BC/BS
www.anthem.com
804.355.8506 in Richmond
800.552.2682 outside of Richmond

Final Appeal
The claim must be at least $300 to be eligible for this process. Within 60 days of the 2nd level appeals decision, submit your final appeal in writing to

Dept. of Human Resource Management
Office of State and Local Health Benefits
101 N. 14th Street, 13th Floor
Richmond, Virginia 23219


UVA Health and Dental Plans

The UVA Health Plan has specific appeals procedures to review the denial or payment of a claim. You can request two levels of appeals with the Claims Administrator, Aetna, if you are dissatisfied with the denial of a medical claim or have a complaint.

  • OptumRx or Aetna performs the appeals for prescription drug coverage, depending on your health option
  • UCCI performs the appeals for the UVA Dental Plan

If you are not satisfied with the decision of the Claims Administrator when the complaint addresses medical decisions, you may pursue the decision further by requesting an external review. In an emergency or in urgent circumstances, you may request an expedited emergency appeals procedure which will provide resolution within one business day of receipt of a complaint concerning situations requiring immediate medical care.

Process

Two Levels of Appeals Through Aetna
www.anthem.com
888.975.9557

Final Appeal Through Aetna
Appeals that address medical decisions may be pursued further. Within 123 days of receiving the 2nd level appeals decision, submit your request to Aetna at 888.975.9557.

Dental Appeals Through UCCI
www.ucci.com
866.215.2354

External Review Through UCCI
Within four months of the Level 2 appeal decision, submit your final appeal in writing to

UCCI Appeals
P.O. Box 69420
Harrisburg, PA 17110