What’s the difference between informal and formal review?
An informal review is the process by which we respond to verbal concerns or complaints and all inquiries. Every effort is made to resolve issues at this level, and informal review matters are often resolved within a single phone call. These issues are frequently related to day-to-day matters, such as verification of benefits or eligibility, interpretation of the insurance contract, clarifications of billing statements or EOB statements, and case management matters. A formal review is how we usually respond to grievances and appeals. This level of review requires us to follow a four-part system to appropriately investigate, resolve, document, and report grievances and appeals. Once we establish that a formal review is necessary, the grievance or appeal is forwarded to a Grievance Coordinator, who is responsible for coordinating a review of the matter and keeping the member informed about our decision.
