What is an appeal?
An appeal is a request from a member, or an authorized representative, acting for the member, to reconsider a decision about the member’s benefit or claim.
Typical appeals include: a denied or partially denied claim, a claim the member believes should have paid more. For medical-necessity decisions(for example a knee surgery), members should go directly to provider office - asking the provider to resubmit through the associate network (for example, Cigna).
Who can appeal?
Only members and authorized representatives can appeal. Providers can ask questions or dispute payment, but cannot appeal without the member's consent.
A family relationship is not authorization. A valid authorization form is required.
For a minor, a parent or guardian may act when legally authorized (over 13 requires an authorization).
Members or authorized representative can contact customer support via email: support@yuzu.health or mail to initiate an appeal. Once the appeals have been verified, Yuzu internal team will open a case.
When can members expect a result?
Most appeals are received post-service (claims already happened). A appeal will be reviewed within 60 days from the date the appeal was received. An outcome will communicate to the member of interest via email.
If an appeal needs to be revisited, a new case will be created: a closed case will not be re-open but will be referenced in the new case.
Outcome | Meaning (ex.) |
|---|---|
Uphold | Decision stands (denial or non-payment supported) |
Overturn | Decision changes - pay or pay more |
Closed | Outcome communicated, nothing pending |