A formal review request of an Action (Denial) or Adverse Plan Determination is known as what?

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An Appeal refers to the formal process by which a member can request a review of an adverse decision made by a health plan, such as a denial or adverse determination. This process is critical because it allows members to contest decisions that they believe are unjust or incorrect. Through an Appeal, members can provide additional information or evidence that supports their case, which the health plan must then reconsider.

It's important to understand that Appeals serve as a structured mechanism within healthcare regulations, ensuring that members have a fair opportunity to challenge and seek resolution on decisions that affect their healthcare access and coverage. This contrasts with the other terms: while a Grievance is typically about dissatisfaction with any aspect of health plan services, an Inquiry refers to questions and clarifications rather than contesting a specific decision. A Request for Review may seem similar, but it doesn't channel through the formal Appeals process that is specifically outlined in healthcare policy.

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