February 26, 1999 (retyped by Nancy Lee for posting, names/IDs edited, on 9/1/99)
Nancy R. Lee
(city, state, zip)
Re: Member ID#: (xxxxxxxxxx)
Reference #: (xxxxxxxxxx)
Dear Ms. Lee:
Intergroup of Arizona has received a request for referral to Scottsdale Healthcare, dated February 18, 1999, for Arterial Embolization. According to your Intergroup Evidence of Coverage, your plan does not cover experimental or investigational procedures. Following medical review, this request was not authorized because the service requested is considered to be experimental and, therefore, not a covered benefit under your plan. For further explanation of your benefits, please call a Member Services Representative at the number listed below.
Intergroup does not deny you the right to obtain the requested service. However, we will not reimburse the provider or the member for services which have not been pre-authorized by Intergroup. You will be responsible for services rendered by this provider.
If you feel that your request has been denied inappropriately, you have the right to a reconsideration of our decision. For a detailed explanation of the complaint and appeal procedure, please refer to your Evidence of Coverage. If you have any questions, please feel free to contact Customer Service at 1-800-289-2818 at Ext. 7440 or (520) 290-7440.
To file a formal appeal, you must do so within 60 days from receipt of this notice. You may make a request in writing to Intergroup at the address below:
Member Inquiry Department
930 N. Finance Center Dr.
Tucson, AZ 85710
(520) 290-7440 or 1-800-289-2818, Ext. 7440
When you request a reconsideration, you should include a copy of this notice and a statement or evidence of why you think the service should be covered by Intergroup. Someone at Intergroup not involved with the initial determination will reconsider your request within thirty (30) days.
(medical director), MD
Associate Medical Director