A request from a member or provider for a formal review of a denial is known as what?

A request from a member or provider for a formal review of a denial is known as an appeal. In the context of healthcare and insurance, an appeal specifically refers to the process by which an individual (usually a member or provider) challenges a decision made by the insurance company regarding coverage or claims, typically after a denial has been issued.

By initiating an appeal, the member or provider is formally requesting that the insurance company re-evaluate the original decision, often by providing additional evidence or justification for why the claim should be approved. This process is a crucial part of ensuring that members have a voice in the decision-making process related to their healthcare coverage.

On the other hand, inquiries generally refer to questions or requests for information and do not involve a challenge to a decision. Complaints typically address dissatisfaction with service or treatment rather than disputes over specific coverage decisions. Reconsideration is often an internal review process that may occur before the formal appeal, but it does not have the same level of structure or formal process as an appeal.

Understanding the difference between these terms is important for navigating the healthcare system and for advocating for appropriate care and coverage.