Quality Management Information for Providers
Notification of Right to Appeal
You may appeal a Quest decision regarding denial of services and resolution of complaints. When a denial of services occurs, you will be notified in writing of how to appeal the decision. You will have 180 days to appeal after you have received notification of a denial. There is one level of appeal available through Quest. During the appeal process, Quest gathers any additional, relevant information and forwards the case to a peer reviewer in the specialty that typically treats the condition or performs the procedure. The peer reviewer will have had no prior involvement in the denial. The member or designee may review any of the documents or other relevant information. The appeal will be completed within 30 days of the request if member has not yet received the service in question or within 60 days if the service has already been provided.
The member may qualify for an expedited review if a delay in decision-making would jeopardize the member's life, health or ability to regain maximum functioning; if the request concerns an admission, continued stay or other health care service for a member who has received emergency services but has not been discharged from the facility; or if without treatment the member would be subject to severe pain based on the opinion of the member's practitioner. An expedited appeal would be completed within 72 hours of the receipt of the request.
Under some circumstances, appeals may be eligible for an external review overseen by the Pennsylvania Department of Health or Department of Insurance. For more information contact the Department of Health at 877-724-3258, The Department of Insurance at 717/787-7000, or Quest at 800-364-6352.
