Fillable Form 1: HHS-Administered Federal External Review Request Form (Superior HealthPlan)

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Form 1: HHS-Administered Federal External Review Request Form (Superior HealthPlan)

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The Form 1: HHS-Administered Federal External Review Request Form (Superior HealthPlan) form is 4 pages long and contains:

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1
Questions?
Call 1-888-866-6205 Monday – Friday 8:00am – 5:00pm EST
HHS-Administered Federal External
Review Request Form
MAXIMUS Federal Services needs the information on this form to review your
medical claim. We may not be able to do the review without this information.
In most cases, you must complete any mandatory appeals or opportunities for
reconsideration offered by your health plan or insurance issuer before we can do
an external review. In urgent situations, we may be able to do a review even if
you have not made all appeals and reconsiderations.
We must receive the completed form within four months of the date your insurer
sent you a final decision denying your services or your claim for payment.
Please read and complete all sections of this form.
Section 1: Covered person
This section is about the person who received or will receive the benefit or treatment.
Name: Email address:
Street address:
City: County: State: Zip code:
Daytime phone: Evening phone:
Please complete this section if you are the covered person’s parent or legal guardian
Name: Email address:
Street address:
City: County: State: Zip code:
Daytime phone: Evening phone:
2
Questions?
Call 1-888-866-6205 Monday – Friday 8:00am – 5:00pm EST
Section 2: Insurance company information
Please complete this section for each insurance company involved with your claim.
Insurance company #1: Insurance plan or plan option (if applicable):
Policyholder: Policy number:
Claim number: Insurance company phone number:
Please attach a copy of the claim that was denied or any correspondence you have received from your
insurance carrier. Please do not send originals. Send only copies.
Insurance company #2: Insurance plan or plan option (if applicable):
Policyholder: Policy number:
Claim number: Insurance company phone number:
Please attach a copy of the claim that was denied or any correspondence you have received from your
insurance carrier. Please do not send originals. Send only copies.
Section 3: Services in dispute
Please describe the health services that were denied by your health insurance plan or issuer:
Have you already received these health services?
Yes
No
If so, when were the services received? (Month, day, year)
_______________________________________________________________________
Please state the reason that you believe the health insurance company’s decision was not correct:
3
Questions?
Call 1-888-866-6205 Monday – Friday 8:00am – 5:00pm EST
Section 4: Claims for urgent care situations
If you believe your situation is urgent, you may ask for an expedited (fast) review.
An urgent care situation is one in which your health may be in serious jeopardy or, in your doctor’s opinion
you may have pain that cannot be controlled while you wait for the external review decision.
To ask for an expedited external review:
Fax this form to 1-888-866-6190
OR mail this form to:
HHS Federal External Review Request, MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705,
Pittsford, NY 14534.
In urgent care situations, MAXIMUS Federal Services will accept a request for external review from a
medical professional who knows about the claimant’s condition. The medical professional will not be
required to submit proof of authorization.
If you have questions about your external review, call: 1-888-866-6205
Is this external review for urgent care?
Yes
No
Section 5: Claims involving a rescission of coverage
A rescission is an action by a health insurance issuer to retroactively cancel (back to an earlier date)
or discontinue a policyholder’s coverage.
Is this request for external review of a rescission of health insurance coverage?
Yes
No
Section 6: Additional information you may give
MAXIMUS Federal Services will use the information on this form to get the relevant information and
documents from your insurer. You may add supporting information and documents you think the insurer
may not be able to provide.
For example, you may choose to give us:
Documents to support the claim, such as physicians’ letters, reports, bills, medical records, and
Explanation of Benefits (EOB) forms
Letters you sent to your insurance plan or issuer about the claim
Letters the plan or issuer sent to you about the claim
You do not have to give us this additional information. However, if you do not give us any additional
information, MAXIMUS Federal Services may decide your case based only on the information your
insurance issuer or plan gives us.
You can give MAXIMUS additional information for your external review by sending it with this form:
Fax to 1-888-866-6190
OR mail this form to:
HHS Federal External Review Request, MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705,
Pittsford, NY 14534.
If you have questions about your external review, call 1-888-866-6205.
4
Sign the consent form.
Please sign and date the form.
Signature:
____________________________________________________________________________________________ Date: _______________________________________________________________
Printed name: _____________________________________________________________________________________
I am the:
Covered person
Parent or legal guardian
Authorized Representative
NOTE: The covered person must sign this consent form, unless they have a legal guardian, personal
representative, are incapacitated, or have otherwise delegated authority to complete this form. If the covered
person cannot sign this form, the authorized representative must give written proof of his or her authority to sign.
You may write or call MAXIMUS in order to obtain a form to allow appointment of an Authorized Representative.
Privacy Act Statement: The following website provides a notice of your rights under the Privacy Act and
includes information about how the information on this form will be used and about our legal authority to
collect this information: http://cciio.cms.gov/resources/other/index.html.
Questions?
Call 1-888-866-6205 Monday – Friday 8:00am – 5:00pm EST
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Form 1: HHS-Administered Federal External Review Request Form (Superior HealthPlan)

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Completed 22 February 2021

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