Alert: The law permits exceptions to the refund requirement in two cases:
this notice. Your request for review should include any additional
information necessary to support your position. If you request an appeal
within 30 days of receiving this notice, you may delay refunding the
amount to the patient until you receive the results of the review. If the
review decision is favorable to you, you do not need to make any refund.
If, however, the review is unfavorable, the law specifies that you must
make the refund within 15 days of receiving the unfavorable review
decision. The law also permits you to request an appeal at any time
within 120 days of the date you receive this notice. However, an appeal
request that is received more than 30 days after the date of this notice,
- If you did not know, and could not have reasonably been expected to
does not permit you to delay making the refund. Regardless of when a
review is requested, the patient will be notified that you have requested
one, and will receive a copy of the determination. The patient has
received a separate notice of this denial decision. The notice advises
that he/she may be entitled to a refund of any amounts paid, if you
should have known that we would not pay and did not tell him/her. It also
instructs the patient to contact our office if he/she does not hear
anything about a refund within 30 days
know, that we would not pay for this service; or - If you notified the
patient in writing before providing the service that you believed that we
were likely to deny the ser
vice, and the patient signed a statement agreeing to pay for the service.
If you come within either exception, or if you believe the carrier was
wrong in its determination that we do not pay for this service, you
should request appeal of this determination within 30 days of the date of
