Appeal Forms. |
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If you would like to make an appeal and your state information is not listed below, please use the generic “Your Internal Appeal, External Review & Grievance."
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Illinois
Indiana
For Indiana Residents Who Purchased an Accident and Sickness Product and those covered by a Blanket Accident and Sickness Policy issued in Indiana:
You may at any time ask Us or Our Administrator for an estimate of the amount We will pay for, or reimburse to you, for non-emergency health care services that have been ordered for you. You may also ask Us or Our Administrator for the applicable benefit limitations that apply to the ordered non-emergency health care services you are entitled to receive under your coverage. The law requires that an estimate be provided to you within five (5) business days.
You may at any time ask Us or Our Administrator for an estimate of the amount We will pay for, or reimburse to you, for non-emergency health care services that have been ordered for you. You may also ask Us or Our Administrator for the applicable benefit limitations that apply to the ordered non-emergency health care services you are entitled to receive under your coverage. The law requires that an estimate be provided to you within five (5) business days.