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Effective January 1, 1998, either the individual, a physician or an appointed representative can request an expedited appeal if life, health, or ability to regain maximum function could be jeopardized by waiting for a decision under the standard 60 day organization determination process.

A request for a review can be made in writing or orally. The health plan has 72 hours from the time the request is made to make a decision, therefore, if a request is made at 6:00 pm on Friday, the health plan is required to make a decision by 6:00 pm on Monday.

Expedited appeals can be filed for many different types of care which may be denied by the health plan. For example, individuals in a rehabilitation hospital and skilled nursing facility who have a continued stay denied can file an appeal.

Denial of physical therapy within six months of a stroke, head injury/surgery, joint surgery (hip, total knee) or other acute trauma can be appealed. In addition, denial of first time requests for physical therapy within four months of a stroke, head injury/surgery, joint surgery or other acute trauma are eligible for appeal.

Expedited appeals can be filed for requested or denied continued home health services; chemotherapy, radiation therapy or proposed surgical treatment of a known malignancy; and AIDS therapy.

Any denial of a proposed "experimental" treatment in a terminal patient appealed using the expedited process. Physicians can request this type of an appeal. Lastly, when a surgery or test has been scheduled, but an authorization for service has not been received, an expedited appeal can be filed.

For assistance in filing an expedited appeal, call 303-333-3482.