1. A doctor recommends additional testing:
a. Your GP office will contact CNIC letting them know they would like to have this done
b. A CNIC representative (Nurse Practitioner or Doctor) will then review and approve or deny based on their own review and understanding of our policy.
i. If approved
1. Insurance will cover the testing
ii. If denied
1. CNIC will contact you and your doctor letting you both know the testing was denied BUT you may appeal this with additional information that may change what they are initially seeing and understanding of that particular case.
a. If appealed:
i. You and your doctor will submit additional information in order to give CNIC a better understanding of why you might need this particular test.
1. If approved:
a. Insurance will cover the testing
2. If Denied:
a. YOU MAY STILL APPEAL A SECOND TIME:
2. Second Appeal:
a. Your appeal will be taken to the Insurance Committee
i. Your situation will be presented to us (anonymously) and we then will discuss the implications of what should happen. We can at this point overturn CNIC’s finding or hold with their findings:
1. If approved:
a. Insurance will cover the testing
i. ***Since this will now be essentially something the insurance plan is “giving” you it will be considered income on your end and will be taxed accordingly
b. All members on our insurance plan at this point will also now be able to get this same treatment
2. If denied:
a. Your testing can still be denied but you still have another option
b. Third Appeal
3. Third Appeal:
a. If at this time you and your doctor still feel this test is necessary and paramount you may appeal to a third level of appeal
i. A group of medical professionals will be found and put together that are nonbiased towards you or the district and they will review your case
1. They can ask for additional information at this point as well
ii. Based on all of the information they get and review they will make a decision
1. If approved:
a. You will be allowed to go forward with your test
b. This will also be treated like the second level of appeals as far as tax goes
2. If denied:
a. It has been found based on medical expertise that you do not “need” this particular testing and the insurance will not cover it.
A few things:
1. Honestly, a lot of this can be taken care of without jumping through hoops. Just contacting Sheila Naski who essentially “runs” our insurance plan for the district is always a great first step:
a. Sheila.Naski@d51schools.org
b. (970) 254-5176
2. IF you have a complaint about CNIC and would like to get more information about what our plan covers and doesn’t cover you may contact our CNIC rep.: Clara Swenson
a. clara.swenson@rmhp.org
b. (970) 244-7852
a. Your GP office will contact CNIC letting them know they would like to have this done
b. A CNIC representative (Nurse Practitioner or Doctor) will then review and approve or deny based on their own review and understanding of our policy.
i. If approved
1. Insurance will cover the testing
ii. If denied
1. CNIC will contact you and your doctor letting you both know the testing was denied BUT you may appeal this with additional information that may change what they are initially seeing and understanding of that particular case.
a. If appealed:
i. You and your doctor will submit additional information in order to give CNIC a better understanding of why you might need this particular test.
1. If approved:
a. Insurance will cover the testing
2. If Denied:
a. YOU MAY STILL APPEAL A SECOND TIME:
2. Second Appeal:
a. Your appeal will be taken to the Insurance Committee
i. Your situation will be presented to us (anonymously) and we then will discuss the implications of what should happen. We can at this point overturn CNIC’s finding or hold with their findings:
1. If approved:
a. Insurance will cover the testing
i. ***Since this will now be essentially something the insurance plan is “giving” you it will be considered income on your end and will be taxed accordingly
b. All members on our insurance plan at this point will also now be able to get this same treatment
2. If denied:
a. Your testing can still be denied but you still have another option
b. Third Appeal
3. Third Appeal:
a. If at this time you and your doctor still feel this test is necessary and paramount you may appeal to a third level of appeal
i. A group of medical professionals will be found and put together that are nonbiased towards you or the district and they will review your case
1. They can ask for additional information at this point as well
ii. Based on all of the information they get and review they will make a decision
1. If approved:
a. You will be allowed to go forward with your test
b. This will also be treated like the second level of appeals as far as tax goes
2. If denied:
a. It has been found based on medical expertise that you do not “need” this particular testing and the insurance will not cover it.
A few things:
1. Honestly, a lot of this can be taken care of without jumping through hoops. Just contacting Sheila Naski who essentially “runs” our insurance plan for the district is always a great first step:
a. Sheila.Naski@d51schools.org
b. (970) 254-5176
2. IF you have a complaint about CNIC and would like to get more information about what our plan covers and doesn’t cover you may contact our CNIC rep.: Clara Swenson
a. clara.swenson@rmhp.org
b. (970) 244-7852