Appeals &

Questions about
your coverage

For questions about coverage, start by calling your health plan at the number on your ID card. A customer service representative will try to answer your coverage questions.

Who may file an appeal?

A patient or a party authorized by the member, a physician, another ordering provider, or a facility rendering service has the right to request an appeal if they disagree with MedCom’s decision that the treatment, procedures, or services do not meet medical necessity criteria or are determined to be experimental or investigational.

If the person acting on behalf of the patient is not their legal guardian, a physician, another ordering provider, or a facility rendering service, an Authorized Representative Designation form may be requested by contacting MedCom at (800) 643-4416.

How to appeal a medical necessity denial?

Your benefit plan determines the specific appeal process that applies to you and follows state and/or federal rules that apply to that benefit plan.

To appeal a claim for medical necessity, a patient may do one of the following:

  • CALL the medical department for MedCom:
    • English: Call MedCom’s medical management department at (800) 643-4416
    • Spanish: Llame al departamento de administración médica de MedCom al (800) 643-4416
    • Chinese: 致电 (800) 643-4416 联系 MedCom 的医疗管理部门
  • FAX the MedCom medical department at (985) 898-1505
  • MAIL a written appeal to:
    • MedCom Care Management
    • 2100 Covington Centre
    • Suite B
    • Covington, LA 70433

The appeal request should include:

  • The member’s name and their personal identification number
  • The group name or identification number, as well as the U-case reference number (the identifier assigned to the original request for certification)
  • All facts and theories supporting the claim for benefits
  • A statement in clear and concise terms of the reason(s) for disagreement with the handling of the claim
  • Any material or information which indicates the patient is entitled to benefits under the plan
NOTE:  If the appeal request is made by someone who is not the patient’s legal guardian, or is a physician or other ordering provider, or a facility rendering service, a signed and dated Authorized Representative Designation Form must accompany the appeal request. Authorized Representative Designation Form can be requested from MedCom at (800) 643-4416.

What happens after I submit my appeal request?

Once the appeal request is received, MedCom will forward all comments, documents, and other submitted information related to the claim to an Independent Review Organization (IRO). A healthcare professional, who was not involved in the medical judgment, will be assigned by the IRO to review the case.

Appeals involving non-urgent claims will be subject to a standard appeal review with a written response within 30 days from receipt of the request for appeal. Appeals involving urgent care claims will be subject to an expedited appeal review. Applicable urgent care claims will be reviewed and responded to as soon as possible, within 72 hours from the receipt of the request for appeal. Retrospective denials for admission, service, or procedure are not eligible for the expedited appeals process.

If the admission, service, or procedure requested continues to be denied, or you do not receive a timely decision, you may request another external review of your claim by an independent third party who will review the denial and issue a final decision.

Complaint Process

To express dissatisfaction regarding MedCom’s products or services, a patient may do one of the following:

  • CALL the medical management department at (800) 643-4416.
  • MAIL a written complaint, or deliver the complaint in person to:
    • MedCom Care Management
    • 2100 Covington Centre
    • Suite B
    • Covington, LA 70433
  • COMPLETE MedCom’s online Satisfaction Survey by clicking the link below:

Let’s Talk

Have questions about whether MedCom is right for your organization? Reach out and one of our sales team will be in touch soon. We’d love to learn more about your organization and to see if Medcom can help.

For all support-related inquiries, please contact our medical management department.

Lets Talk

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