However, some large, self-funded employer groups have benefit plans that require additional regulatory procedures and may have customized timelines and other protocols that deviate from the process We have a defined appeal/grievance process for members and their treating providers. If the provider or member does not provide documentation, we will decide the appeal using only the information we already have. We do not solicit records to support an appeal/grievance. The provider and member are responsible for sending all relevant information to support a dispute and show why we should change our original decision.
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