Medical Appeals

Medical, Pharmacy, and Wellness Appeals

SHBP has delegated full responsibility for claims administration including medical, pharmacy and wellness appeals to our medical claims administrators, Anthem Blue Cross and Blue Shield, Kaiser Permanente, and UnitedHealthcare; our pharmacy benefits manager, CVS Caremark; and wellness administrator, Sharecare for Anthem and UnitedHealthcare Commercial non-Medicare plan options.

Therefore, these types of appeals are outside the scope of eligibility and enrollment appeals handled directly by SHBP through the Tier I Telephone Review and Tier II Formal Appeals Process.

Examples of medical, pharmacy or wellness appeals include, but are not limited to adverse actions such as:

  • Medical claims denials
  • Surgical procedure denials
  • Prescription prior authorization denials
  • Wellness incentive credit denials

To initiate a medical, pharmacy or wellness appeal, please contact the appropriate administrator via the contact information on the back of your ID Card, contact information available on the SHBP website, or by contacting SHBP Member Services at 800-610-1863 and selecting the prompt to be connected to your administrator.