An internal review allows Select Health to reconsider a coverage decision. Learn when an appeal may be requested and what information is needed.
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Appeals & reviews
Understand your options for appealing a coverage decision, requesting a review, and submitting required information.
Request an internal review
Independent external review
In certain situations, decisions may qualify for review by an independent third party after applicable internal review requirements have been met.
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Standard review timeframes
Review the timelines for standard coverage determinations, appeals, and reviews so you know what to expect.
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Medication exception reviews
In certain situations, decisions may qualify for review by an independent third party after applicable internal review requirements have been met.
Internal medication exception process
- Your prescriber submits a request. To start an exception request, your prescriber submits a preauthorization (PA) request for the non-formulary medication, along with a statement explaining why it is medically necessary for your condition.
- We review and decide. We notify you and your prescriber of our decision within the timeframes listed below.
- If we deny the request, you can appeal. You or your prescriber may request an appeal, and we will review the original decision.
- We send you a communication of our decision. If we uphold the denial, our communication explains your right to request an external review.
External medication exception process (independent review)
If we uphold a denial of your formulary exception request, you have the right to an external review. You or your prescriber may request that the original exception request and our denial be reviewed by an Independent Review Organization (IRO), a qualified third party not connected to Select Health.
Once we receive your request for external review, we forward it to the IRO. The IRO reviews the case, sends us its decision, and we communicate that decision to you and your prescriber. The IRO's decision is binding.
Appeals submission instructions
An appeal is a request to review an Adverse Benefit Determination. Essentially, you ask that we double-check our decision to make sure we made the correct ruling on your claim.
If you have a problem with an Adverse Benefit Determination, please call Member Services. They can help you work through most problems. If you still need help or have additional questions, you can file an appeal online.
