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
UVA Health Plan
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.
- Catamaran or Aetna performs the appeals for prescription drug coverage
- 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.