Important Information about the denial of a requested service

This information is about a service or treatment your health care provider recently asked us to cover. We have denied this request. You have the right to ask us to change our decision. We must receive your request within 45 days from the Date of Notice listed on the enclosed Notice.

Please call us at the phone number on the enclosed Notice right away if:

• 
  You do not understand the Notice.
  
• 
  You need the Notice in large print, a different format or language. An interpreter will translate the document at no cost to you.
  

Esta información corresponde al servicio o tratamiento que su proveedor de atención médica nos pidió recientemente que cubramos. Hemos denegado tal solicitud. Usted tiene el derecho de pedirnos que cambiemos nuestra decisión. Deberemos recibir su solicitud dentro de los 45 días a partir de la fecha de aviso que aparece en el aviso adjunto.

Llámenos de inmediato al número de teléfono que se indica en el aviso adjunto si:

• 
  No entiende el aviso.
  
• 
  Necesita el aviso en letra grande, en otro idioma o formato. Un intérprete traducirá el documento de forma gratuita para usted.
  

Данная информация относится к оплате услуг или процедур, которые были представлены к оплате вашим врачом. Данный запрос был отклонен. Вы имеете право подать прошение об изменении данного решения. Для этого ваш запрос должен быть получен в течение 45 дней от даты издания, указанного в приложенном уведомлении.

Пожалуйста, позвоните нам как можно скорее по номеру телефона, указанному в приложенном уведомлении если:

• 
  Вы не понимаете смысла данного уведомления.
  
• 
  Данное уведомление необходимо вам крупным шрифтом, в другом формате или на другом языке. Переводчик сможет помочь вам прочитать его совершенно бесплатно для вас.
  

Tin tức này về dịch vụ hoặc điều trị mà nơi cung cấp dịch vụ săn sóc y tế của quý vị hồi gần đây đã yêu cầu chúng tôi chi trả. Chúng tôi đã từ chối yêu cầu này. Quý vị có quyền yêu cầu chúng tôi thay đổi quyết định. Chúng tôi phải nhận được yêu cầu của quý vị trong vòng 45 ngày kể Ngày của Thông Báo được ghi trên Thông Báo đính kèm.

Xin gọi điện thoại cho số được ghi trên Thông Báo đính kèm ngay tức khắc, nếu:

• 
  Quý vị không hiểu nội dung bản Thông Báo.
  
• 
  Quý vị cần bản Thông Báo in khổ chữ lớn, bằng hình thức hoặc ngôn ngữ khác. Một thông dịch viên sẽ thông dịch tài liệu miễn phí giúp quý vị.
  

本文含有您的医疗保健提供者近日请求我们承保某项医疗服务或治疗方案的相关信息。我们拒绝了此项请求。您有权要求我们改变决定。请务必自随附通知书中所列通知日期起 45 天内发送您的请求。

如果出现下列情况，请立即拨打随附通知中的电话号码联系我们：

• 
  您不理解通知书的内容。
  
• 
  您希望我们以大号字体、不同的格式或语言向您发送的通知书。我们将向您免费提供文件翻译服务。
  

Macluumaadkani wuxuu ku saabsan yahay adeeg ama daaweyn uu daryeel caafimaad fidiyahaagu dhawaan naga codsatay in aanu bixino. Waan diidnay codsigani. Waxaad xaq u leedahay in aad naga codsato in aanu beddelno go’aankayaga. Waa in aan codsigaaga ku helnaa mudo 45 maalmood gudahood ah laga soo bilaabo Taariikhda Ogeysiiska lagu qoray Ogaysiinta ku lifaaqan.

Fadlan isla markiiba naga soo wac lambarka telefoonka ku lifaaqan Ogaysiinta haddii:

• 
  Aadan fahmin Ogaysiinta.
  
• 
  Aad u baahan tahay Ogaysiinta oo ku qoran far waaweyn, iyadoo u qoran qaabkale ama luqad kale. Turjubaan ayaa lacag la’aan kuugu turjumi doona qoraalka.
  

Member Name: Client Name

Address:

ID Number: Client ID

Date of Birth: Client DOB

PCP/PCD: PCP/PCD Name

Dear Client Name,

We got your appeal request on Date. You asked us to cover Description of the denied service or item ordered by Doctor Name. After the appeal, our decision is to cover/not to cover it.

This decision is based on Oregon Administrative Rule(s) provide the legal citation (rule, regulation, statute), including specific references to applicable sections or subsections, that correspond to each reason provided above for denying the claim .

You may get the information we used in making this decision in writing. To get a copy, call Customer Services at 555-555-5555 or 555-555-5555 TTY, Monday to Friday, 8 am - 5 pm.

Things you can do if you disagree with this Notice

If you disagree with our decision, you have the right to ask for a state fair hearing. Send your hearing request to the state or you insurance company within 120 days from the Date of Notice above.

The enclosed Denial of medical services - Appeal and hearing request has instructions for requesting a hearing.

Continuing services

To keep getting this service while you wait for your state hearing, you must:

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  Have already been getting the service before it was denied,
  
• 
  Request for services to be continued by checking Box 4 on the enclosed Denial of medical services - Appeal and hearing request, and
  
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  Ask for a Hearing within 10 days from the “Date of Notice” or by the “Effective Date” shown on this Notice, whichever is later.
  

You or your provider can ask for an expedited (fast) Hearing if you have a condition which is an immediate, serious threat to your life or health and you would be harmed by waiting the usual amount of time for a Hearing.

A nurse or doctor will review your request and decide within two working days if your condition needs an expedited Hearing.

Other things you can do

There are other things you can do besides requesting a Hearing. See page 4 of the enclosed Denial of medical services - Appeal and hearing request for more information.

If you have questions, please contact Customer Services at:

Phone: 555-555-5555 or 711 (TTY) (Customer Services hours – Monday to Friday, 8 am - 5 pm)

Fax: 555-555-5555