Care Management Programs
Utilization Management Overview
Utilization management (UM) evaluates the medical necessity and appropriateness of healthcare services provided to a member or eligible dependent. This helps ensure that approved services are the most appropriate for the illness or injury and are provided at the most cost-efficient level of care.
The UM program performs prospective, concurrent and retrospective reviews. During the utilization review process, additional clinical documentation may be required to substantiate the medical necessity and appropriateness of care. The program staff will evaluate services based on accepted standards of medical practice, evidence-based guidelines, clinical policies and procedures and covered services, including prior authorization requirements, as defined in each Fund’s Summary Plan Description (SPD).
Prior authorization and pre-certification requirements are regularly updated and are, therefore, subject to change. We recommend you periodically visit our Prior Authorization page and review the 1199SEIU Benefit Funds’ Provider Connections newsletters to keep apace of updates.
Outpatient, Durable Medical Equipment and Home Care Services Requiring Prior Authorization
To effectively coordinate member care, the 1199SEIU Benefit Funds require certain outpatient services, durable medical equipment (DME), prosthetics and home care services to be preauthorized before they can be provided or performed and be eligible for benefit consideration. See our Prior Authorization page for a list of procedures requiring prior authorization and the forms to request these services.
Make sure you have authorization before starting the service or providing durable medical equipment; otherwise, the Benefit Funds will not cover the service and the claim will be denied. Regarding emergency services, providers should notify the Benefit Funds as soon as practical.
You can contact our Prior Authorization Call Center Monday through Friday between the hours of 9:00 am and 5:00 pm at (646) 473-7446 with any inquiries, and you can access the forms for authorization requests on our website.
Providers may submit an authorization request by fax to (646) 473-7447. Please include your fax and tax identification numbers (TIN) with your requests. To streamline the notification process, the Benefit Funds will fax you the determination notice.
Timeframes for initial benefit decisions
- A pre-service care request must be determined no later than 15 days from the date the Benefit Funds receive the request. This 15-day period may be extended by the Benefit Funds for an additional 15 days due to matters beyond the Benefit Funds’ control; you will receive prior written notice of the extension.
- An urgent care request will be treated as such if the treating physician and the Benefit Funds’ Medical Advisor believe that the waiting time for decision-making could seriously affect the life or health of the patient. These requests will be reviewed as soon as possible but no later than within 72 hours of receipt of the request.
- A concurrent care request will be reviewed and, if indicated, an adverse determination will be sent sufficiently in advance of the reduction or termination of benefits to allow you to appeal and obtain a decision before the benefit is reduced or terminated.
Note: A pre-service authorization is valid for 90 days from the date issued.
Authorizations are assigned a 10-digit reference ID, which should be used for any follow-up inquiries.
If your Coverage Determination Notice from the Benefit Funds lists specific CPT/HCPCS codes, you must use the same codes when you submit your claim or bill for payment. This matching of codes will assure the accuracy and timeliness of your payment.
Medical Review Outpatient Programs Requiring Prior Authorization
Selective outpatient services requiring prior authorization
The Benefit Funds’ medical review partnership for selective outpatient services allows providers to access the program’s experts, as well as nationally recognized evidence-based guidelines and criteria, to help ensure Benefit Funds members receive clinically appropriate care in a timely manner.
The follow services require prior authorization and are subject to claims review:
- Radiology services (includes MRA/MRI, CT/CTA and PET imaging studies, as well as nuclear cardiology services)
- Radiation therapy services
- Medical oncology services
- Laboratory tests (includes molecular and genomic laboratory services)
Medical review programs are subject to updates, so please check our Medical Review Programs page regularly to help ensure you have the most up-to-date information.
In the event of a pre-service adverse determination, the provider may request a clinical review. A peer-to-peer physician discussion can be conducted any time during the determination, and up to 14 calendar days after the determination, to add additional information that may affect the outcome of the medical necessity decision. Visit our Prior Authorization page for a list of programs and contacts.
- Pre-service authorization is valid for 60 days from the date issued for radiology and outpatient molecular and genomic laboratory services.
- Pre-service authorization varies and is valid for eight weeks to up to six months from the date issued for radiation therapy.
- Pre-service authorization varies and is valid for up to 14 months from the date issued for medical oncology.
Prescription Drugs Requiring Authorization
The 1199SEIU Benefit Funds and its Pharmacy Benefit Management Program require authorization for certain medications, and prior authorization, step therapy and quantity duration requirements are regularly updated and subject to change. Participating providers should routinely check the Benefit Funds’ Prior Authorization page and the Utilization Management Master Drug List page for updates and a complete list of medications that require prior authorization. Providers should also review all incoming provider email/fax updates and read the Provider Connections e-newsletter for the most up-to-date information.
Your Benefit Funds patients have few or no out-of-pocket costs as long as they use the Benefit Funds’ prescription programs. Help your patients by prescribing only generic and preferred brand-name drugs on the Benefit Funds’ Preferred Drug List (PDL).
- CareContiuum Medical Drug Benefit Management Program
- The 90-Day Rx Solution
- Preferred Drug List
- eviCore Medical Oncology Drug List
- Limited Distribution Specialty Drug List
- Prescription Claims Reimbursement Form
- Prescription Request for Authorization
- Utilization Management Master Drug List
- Pharmacist Authority to Administer Vaccines by State
- Participating Pharmacy Locator by ZIP Code
Please visit our Prescription Program page to download drug-specific Request for Prior Authorization fax forms and for additional information on the program.
Medical Management of Hospital Services
The 1199SEIU Benefit Funds have contracted with CareAllies to provide telephonic medical and behavioral health utilization management services. This includes notification, certification and continued stay reviews for medical necessity, length-of-stay management and level-of-care appropriateness. Many services requiring pre-certification are listed below, though the list changes from time to time. For the current list, visit our Prior Authorization page.
Contact CareAllies at (800) 227-9360. CareAllies staff is available from 8:30 am to 6:00 pm (ET) Monday through Friday.
Before rendering the following services, providers, hospitals and facilities must contact CareAllies or another designated utilization agent acting on behalf of the Benefit Funds:
- All inpatient admissions, including psychiatric and alcohol/substance use disorder treatment
- Inpatient acute physical rehabilitation
- Certain outpatient/ambulatory surgical procedures:
- Transplant evaluation (inpatient/outpatient)
- Bariatric & metabolic surgery (inpatient and outpatient)
- Oral pharynx
- Spine (inpatient and outpatient)
- Electrophysiologic (operative and intra-cardiac)
- Hypoglossal nerve stimulation
- Ventricular assist devices
- Vascular embolization and occlusion
- Osseointegrated implant/removal skull
- Potential cosmetic procedures:
- Breast augmentation
- Skin integumentary
- Eyes, nose, head, ears, trunk, body, jaw, face augmentation
- Vein treatment
- Vascular embolization
- Gender affirming treatments
- Unlisted procedures
- CAR-T therapy (inpatient and outpatient)
For emergency admissions, either you or the Benefit Funds member must contact CareAllies within two business days of an admission.
Pre-service and pre-scheduled determinations are valid for 90 days from the date of certification. If the admission date or the level of care changes, or if additional days are required, CareAllies must be contacted.
Note: If your inpatient stay or outpatient/ambulatory surgical procedure is denied, you may request a physician peer-to-peer review by calling Medical Operations at (800) 253-6647 (fax: (877) 243-9520). Medical Operations staff is available from 8:30 am to 7:00 pm, Monday through Friday.
Selected Outpatient and Ambulatory Surgical Procedures
that Require Pre-Certification
You or your 1199SEIU Benefit Funds member must call CareAllies at (800) 227-9360 before certain outpatient or ambulatory surgical procedures are performed.
For a list of outpatient and/or ambulatory surgical procedures that require pre-certification, refer to the Benefit Funds’ Prior Authorization page. An ambulatory surgery procedure determination is valid for 90 days from certification. If the ambulatory procedure date changes, the level of care changes or if the member is admitted urgently following the outpatient surgery, it is important that you notify CareAllies. Ambulatory surgery, CAR-T therapy and evaluations for transplants require a prospective medical necessity review by CareAllies before the services are performed.
Hospital Discharge Notifications
For hospital discharge notifications, please call CareAllies’ automated system at (800) 378-7456, Monday through Friday, 8:00 am to 9:00 pm (ET). To use the system, you will need the CareAllies case number or the member’s ID number, the admission date and the actual discharge date. This will help ensure prompt and accurate claims processing and payment when your bill is submitted to the 1199SEIU Benefit Funds.
Utilization Review Procedural Guidelines
Covered services for which pre-certification is required are specified in this manual and are updated periodically. We recommend bookmarking our Prior Authorization page to stay up to date on pre-certification requirements. Hospitals should make reasonable efforts to contact CareAllies or another designated utilization review agent acting on behalf of the 1199SEIU Benefit Funds to pre-certify an elective admission or outpatient procedure no less than three business days prior to the scheduled admission or procedure, though hospitals are encouraged to obtain pre-certification as far in advance as possible. CareAllies will communicate the medically necessary decision regarding requested covered services via mail, fax or telephone within five business days after the hospital/provider submits the necessary clinical information.
Hospital inpatient management and time frames
The hospital will notify CareAllies of all inpatient admissions within 24 to 48 hours of admission, or the next business day in the case of weekends and/or holidays, via telephone or fax.
- If the necessary clinical information is provided by the hospital and justifies the admission according to the nationally recognized guidelines or criteria for an acute care setting, the admission will be approved. Approval of the admission will be mailed or faxed to the hospital within three business days for emergent admissions.
- If the clinical information provided does not support a medically necessary inpatient admission, the hospital will be notified via mail, fax or telephone of the decision within one business day of the initial determination. The specific rationale for the decision will be provided. CareAllies can make available the phone number for peer-to-peer discussion with the Medical Director responsible for the determination. If the admission is subsequently approved, the determination will be communicated via fax or telephone to the hospital.
- If the inpatient admission or continued stay is not authorized, the hospital may request an expedited appeal by CareAllies. This can occur when a delay may seriously jeopardize the life or health of the patient or, in the opinion of the treating physician with knowledge of the medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment being requested. A CareAllies physician reviewer, in consultation with the treating physician, will decide if an expedited appeal is necessary. If so, CareAllies will respond no later than 72 hours after receiving your request. An expedited appeal is available, when requested, due to failure to authorize a continuing inpatient hospital stay.
The medical necessity appeal determination will be the final and binding decision for all parties. The hospital will be notified by mail indicating the final determination regarding the inpatient admission or continued stay within three calendar days of the expedited appeal determination; the requester will be notified by phone.
Medical management process for DRG cases
Once a DRG admission is approved as medically necessary, CareAllies will not continue to do medical necessity reviews while the patient is in the DRG inlier. A medical necessity determination will be made prior to low trim and beyond high trim unless there is pertinent clinical information to influence the discharge disposition, care transition and the coordination of services from inpatient to outpatient.
CareAllies will conduct concurrent reviews telephonically with respect to admissions and ongoing outpatient courses of treatment, which are subject to a per diem reimbursement methodology. CareAllies will then notify the hospital of any concurrent determination. All notifications to a hospital will be made to the department indicated by the hospital. If CareAllies provides certification for any portion of the inpatient stay, CareAllies shall not retrospectively deny the certified services except (1) if the services certified were materially different from the services provided; (2) the member’s condition was materially different from the described condition; or (3) the member was retroactively disenrolled. The UM decisions during the concurrent review process will be based on medical necessity by CareAllies or by the Benefit Funds for determinations based on Plan design.
A retrospective review is defined as a review of the medical necessity of a healthcare service that occurs after the service has been delivered or, in the case of inpatient hospitalization, after the patient has been discharged. If the hospital fails to notify CareAllies of an inpatient admission, the claim will be denied for non-compliance with the Benefit Funds’ utilization review procedure. The hospital may submit medical records and/or supporting clinical documentation to CareAllies for a retrospective review within 180 days of the initial denial date. Upon review, if it is determined the covered services provided were all or partially medically necessary, the hospital will be notified via mail, fax or telephone, and if there is a financial impact, the claim will be adjusted. Records must be submitted to CareAllies; any records sent to the Benefit Funds will not be forwarded.
Hospital Appeal and Dispute Resolution Program
Hospitals that wish to dispute total or partial denials of claims and requests (either before the services are performed or after they are completed) must follow the procedures outlined in this manual. Courts shall not have jurisdiction over disputes subject to the dispute procedures.
Decisions rendered through these dispute procedures are final and binding. At no time during the dispute process, or after the final determination, will the hospital bill or collect any monies from the member or the member’s dependent(s).
First-level hospital appeals and disputes—inpatient
For inpatient admissions, if the hospital claim is denied either pre-service (prospectively), concurrently or post-service (retrospectively), the hospital will receive a written notice of the adverse determination, including the following:
- The determination reasons inclusive of the clinical rationale
- Instructions on how to initiate an appeal
- The specific clinical review criteria relied upon to make the determination (available upon request)
The notice shall also specify what, if any, additional necessary information must be provided or obtained in order to render a decision on the appeal. If the hospital disagrees with a total or partial denial for an inpatient, outpatient or ambulatory surgical procedure, other than a DRG determination (see Medical Management Process for DRG Cases above), the hospital may initiate an appeal within 180 days of the initial denial date for all appeals by contacting CareAllies.
For medical appeals, call, write or fax CareAllies at:
1777 Sentry Park West
PO Box 188056
Chattanooga, TN 37422-8056
Telephone: (800) 232-7497 | Fax: (877) 830-8833
For mental health and substance use disorder appeals, call, write or fax Cigna at:
Central Appeals Department
Central Appeals Unit
P.O. Box 188064
Chattanooga, TN 37422
Telephone: (800) 241-4057, ext. 2009 | Fax: (855) 816-3497
Requests for urgent care review can be made to CareAllies by calling (800) 227-9360 or sending a fax to (866) 535-8972 for medical services or (855) 816-3497 for behavioral health services.
The provider’s request must include the specific reason(s) why the hospital disagrees with the initial denial, along with any other pertinent information that supports the request.
CareAllies will telephonically make available a medical director (or other medical professional qualified to render a medical necessity determination) to review the clinical status of the member.
Appeal response times
- Appeals before a service is performed: The response time for a standard pre-service denial of care appeal is 15 days from receipt of the appeal.
- Urgent appeals: If the treating physician believes that waiting the 15 days typical for a pre-service appeal may seriously jeopardize the life or health of the patient or, in the opinion of the treating physician with knowledge of the medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment being requested, the hospital may request an urgent care review. A CareAllies physician reviewer, in consultation with the treating physician, will decide if an expedited appeal is necessary. If so, CareAllies will respond no later than 72 hours after receiving your request. Expedited appeals have a single-level appeal process in which the decision is binding on the hospital and the Benefit Funds.
- Appeals for claim denials after a service is performed: The appeal response time for a standard post-service claim denial is 30 days from the date that CareAllies receives the appeal.
Second-level hospital appeals—inpatient admissions only
If, after the first appeal, the initial decision regarding inpatient admissions is upheld and the hospital disagrees with this decision, the hospital may then request a second-level appeal from CareAllies within 60 days of the first-level appeal determination in the same manner. This second-level appeals procedure applies to inpatient admissions only and does not apply to outpatient services or ambulatory surgery. A CareAllies physician who was not involved in the first-level review will review second-level appeals.
Hospital’s external third-level hospital disputes—inpatient admissions only
For inpatient admissions only, if both the first- and second-level inpatient hospital reviews are partially or fully denied, and the hospital continues to disagree with this decision, the hospital may challenge the determination to Island Peer Review Organization (IPRO), a third-party external utilization management organization that the Benefit Funds have retained.
This independent review is a voluntary third-level review program. The hospital’s request must be submitted directly to IPRO within 60 days of the second-level appeal determination. You should contact IPRO directly at (516) 326-7767, ext. 411. Note that IPRO charges a fee for this third-level review. Please mail or fax your request, along with the medical records and the UM determination notice, to:
1979 Marcus Avenue, 1st Floor
Lake Success, NY 11042
Telephone: (516) 209-5411
Fax: (516) 326-1034
(If you are interested in submitting the medical records and related documents via secure email, please contact IPRO and they will guide you through the process.)
The decision of IPRO is final and binding on the hospital for post-service inpatient claims.
Focus Diagnosis-Related Groups (DRG) Validation Program and the Related Dispute Process
MedReview is a designated utilization review agent acting on behalf of the 1199SEIU Benefit Funds that provides pre-payment and select post-payment utilization review for DRG-based hospital bills. This is also known as the Focus DRG Validation Program, and participation is required of all participating providers. Once a claim has been received, the claim is marked “pending” and sent to MedReview. MedReview will request a copy of the medical records from the hospital. The facilities must use one of the three options listed below when sending medical records to MedReview.
- Upload: [email protected] (this is the preferred method)
- Email: [email protected]
- New York County Health Service Review Organization (NYCHSRO)/MedReview
1 Seaport Plaza, 199 Water Street, 27th Floor
New York, NY, 10038
- New York County Health Service Review Organization (NYCHSRO)/MedReview
Please note: If mailing charts, a copy of the initial record request must be included along with the medical records.
Listed below are the timeframes for facilities to submit medical records once they receive a request from MedReview.
- Facilities have 15 days to respond from the first request for medical records.
- If the medical records are not received, a second and final request is sent, and facilities have 15 days to respond.
- If medical records are not received within 30 days (15 days from the first request, plus 15 days from the second request), MedReview notifies the Benefits Funds, and a technical denial is issued.
- Upon receipt of the medical records, MedReview has 15 days to issue a determination.
Previously processed claims
Revised DRG: When a facility is disputing a previously paid claim and resubmits a new claim with a revised DRG, they must submit medical records, the denial EOB and UB-04 for validation of the rebilled/revised DRG within 180 days of the claim denial date to MedReview using one of the methods listed above.
DRG Validation: A facility may request a reconsideration for claims when the facility is disputing a DRG that was regrouped based on UB-04 diagnosis/procedure codes. They have 180 days from the claim payment date to submit the UB-04, EOB and medical records to MedReview using one of the methods listed above.
If, after the first appeal, the initial decision is upheld and you disagree with this decision, you may then request a second-level appeal from MedReview in the same manner within 90 days of the first-level appeal determination.
If both the first- and second-level administrative reviews are partially or fully denied and you continue to disagree with this decision, you have the option of an external third-level review within 90 days of the second-level dispute determination, as outlined in Hospital’s External Third-level Hospital Disputes—Inpatient Admissions Only.
At no time during the dispute process, or after the final determination, shall the hospital bill or collect any monies from the member or the member’s dependent(s).
Re-Admission Review Program
Payment for medical re-admissions within 30 days of the initial discharge back to the same hospital are pended to MedReview or another agent acting on behalf of the 1199SEIU Benefit Funds. MedReview will request copies of the initial and re-admission medical records for review. If the re-admission could have been prevented by the hospital’s provision of appropriate care prior to discharge or during the post-discharge follow-up period, payment for the re-admission will be denied.
MedReview will notify the hospital of its decision in writing, including the right to appeal. Instructions on submitting a dispute will be provided in the decision letter.
Decisions rendered through the dispute procedures are final and binding. Courts shall not have jurisdiction over disputes subject to the dispute procedures, and at no time during the dispute process, or after the final determination, shall the hospital bill or collect any monies from the member or the member’s dependent(s).
Case Management Program
The 1199SEIU Care Management Program works in partnership with designated hospital personnel, our members, primary caregivers and community providers to establish a plan of care, reduce hospital admissions, identify and address clinical gaps in care and encourage members to use their healthcare benefits appropriately. Within the program, Benefit Funds Care Managers function as the liaison between the healthcare settings and providers with the specific purpose of having one point of contact for a seamless transition from one level of care to another.
Care Management staff assists in the arrangement of post-hospital/community services as needed (e.g., home care, durable medical equipment, outpatient physical therapy, outpatient cardiac and pulmonary rehab and other services) and helps ensure participating providers and vendors are utilized to minimize out-of-pocket costs.
Nurse Case Managers and Care Coordinators objectives include:
- Conducting a comprehensive telephonic assessment of members with selective medical conditions
- Establishing individual members’ goals and care plans
- Addressing medication reconciliation
- Educating members about a healthy lifestyle
- Promoting self-management skills to achieve quality outcomes
- Providing coordination of benefits
- Linking to community resources and health care alternatives
The Care Management Department can be reached at (646) 473-7446.
Behavioral/Mental Health Services Requiring Prior Authorization
Partial hospitalization programs for mental health and intensive outpatient programs for mental health and substance use disorder provide alternate levels of coordinated care; can prevent hospitalizations; and help to restore maximum function in a clinically appropriate setting. These programs are a covered benefit that require prior authorization. Providers should call the 1199SEIU Benefit Funds at (646) 473-6868 prior to beginning services.
Transcranial magnetic stimulation therapy (TMS) is covered by the Benefit Funds for the treatment of major depressive disorder in adults who have failed to receive satisfactory improvement from antidepressant medication while under the care of a psychiatrist. Prior authorization is required. Please call (646) 473-6868.
For prior authorization for inpatient behavioral health and alcohol/substance use disorder care, contact CareAllies at (800) 227-9360, option 2, Monday through Friday, 8:30 am to 6:00 pm.
Provider Claim Dispute Resolution for Medical Claims and Appeals of Pre-Service Authorization Denials
There are different ways participating providers may be able to challenge the 1199SEIU Benefit Funds’ denials of medical claims, depending on the circumstances: providers’ dispute resolution for claim denials (for providers and facilities) or members’ administrative appeal of pre-service authorization denials (for providers appealing on a member’s behalf). For all disputes regarding inpatient hospital admissions, see Hospital Appeal and Dispute Resolution Program, which documents the separate inpatient admissions dispute resolution process handled by the Benefit Funds’ vendors.
Providers’ dispute resolution (excluding inpatient admissions)
When the Benefit Funds deny a claim, in whole or in part, including concurrent and retrospective review determinations, participating providers may dispute that denial on their own behalf. This is the provider’s own dispute resolution process, separate from the members’ administrative appeal process, and providers may not use this process to challenge the Benefit Funds’ eligibility determinations or to assert a member’s rights under the SPD, including challenging the Benefit Funds’ scope of covered services. You will receive an explanation of payment that identifies the basis for the Benefit Funds’ reimbursement determination.
Reconsideration requests for administrative denials
To initiate the dispute resolution process for administrative denials, participating providers may submit a Medical or Hospital Claim Reconsideration Request form contesting the Benefit Funds’ basis for denying the claim within 180 days of the date the claim was originally denied or paid. Through the timely submission of this form, providers may submit proof and/or relevant information in support of their position that the claims should have been paid or reimbursed at a different rate.
To request a claim review, submit a timely and completed Medical or Hospital Claim Reconsideration Request form in writing identifying the reason(s) you disagree with the Benefit Funds’ determination to:
|For CMS1500 claims:
1199SEIU Benefit Funds
|For UB-04 claims:
1199SEIU Benefit Funds
Visit our Forms and Resources for Providers page for the Medical Claim Reconsideration Request and Hospital Claim Reconsideration Request forms. We will respond to your claim review within 90 days of receiving the request.
Reconsideration requests based on utilization review determinations
For reconsideration requests based on utilization review determinations, participating providers may initiate a dispute within 180 days of the initial denial date by contacting the Benefit Funds’ designated vendor that made the initial utilization review determination. This information is provided below.
Members’ administrative appeal (excluding inpatient admissions)
First-level appeals of pre-service authorization denials
When the Benefit Funds or one of its vendors denies a pre-service authorization request and the service has not yet been provided, participating providers may appeal that denial on the patient’s behalf, unless the denial is based on the member’s eligibility or because the service requested is not a covered benefit. To appeal pre-service authorization denials, you must complete a Benefit Fund Appeal Representation Authorization Form. This is not the same as an assignment of benefits designation, and you may not rely on an assignment of benefits to bring an appeal on behalf of a member.
Per the Benefit Funds’ appeal procedure as set forth in the Benefit Funds’ SPDs, members may appeal the denial in writing within 180 days of the initial date of receipt of the adverse benefit determination. First-level appeals are handled by the same entity that handled the pre-service review. For example, the Benefit Funds handle first-level appeals for outpatient and home care services requiring prior authorization, as set forth in Outpatient, Durable Medical Equipment and Home Care Services Requiring Prior Authorization, and eviCore manages first-level appeals for services it pre-authorizes, as set forth in Medical Review Outpatient Programs Requiring Prior Authorization.
Submit first-level appeals, including any records or supporting documentation, by mail or fax to the appropriate entity, using the appeal information provided to the member in the adverse benefit determination or the contact information below:
1199SEIU Benefit Funds
Times Square Station, PO Box 646
New York, NY 10108-0646
Fax: (646) 473-8958
Attn: Clinical Appeal Dept.
400 Buckwalter Place Blvd.
Bluffton, SC 29910
Fax: (844) 545-9214
For appeals process questions, call (866) 221-8787, option 2.
PO Box 188056
Chattanooga, TN 37422-8056
Telephone: (800) 232-7497
Fax: (877) 830-8833
Cigna (EverNorth) (behavioral health and substance use disorder appeals)
Central Appeals Department
Central Appeals Unit
P.O. Box 188064
Chattanooga, TN 37422
Telephone: (800) 241-4057, ext. 2009
Fax: (855) 816-3497
Second-level appeals of pre-service authorization denials
The Benefit Funds manage all second-level outpatient appeals for medical claims. The Benefit Funds’ appeal procedure allows a member/patient to file a second-level appeal within 60 days of receipt of the first-level appeal denial notice.
Only once these appeal procedures are exhausted can a member, or you on the member’s behalf, initiate a lawsuit to challenge the Benefit Funds’ denial.
Submit second-level appeals to the Benefit Funds by mail or fax to:
1199SEIU National Benefit Fund
Times Square Station, PO Box 646
New York, NY 10108-0646
Fax: (646) 473-8958