How to Appeal a Denied Claim

If you believe a claim has been wrongfully denied, either fully or partly, you may submit a written appeal. You will have 180 days from receiving the denial notification to submit an initial appeal with us.

Sana First Health Plan (SFHP): Claims Denied for a Missing Referral

For most care under Sana First, members must complete the Sana Care referral process before receiving care. If you receive care that requires a referral without completing this process first, the claim may be denied and you may be responsible for 100% of the cost.

If your claim was denied for a missing referral:

• If you had a valid referral before receiving care: Contact Sana Support so we can review the claim and referral information. A claim/referral mismatch may need to be corrected rather than appealed.
• If you did not have a referral before receiving care: You may submit an appeal requesting a review of the denied claim. Include any information or documentation that explains the circumstances surrounding the care and why you believe the claim should be reconsidered.

Submitting an appeal does not guarantee that a referral can be approved retroactively or that the claim will be covered. The appeal will be reviewed based on your plan benefits and the information provided.

Emergency Room, Urgent Care, OB/GYN, and pediatric primary and preventive care do not require a Sana Care referral.

All appeals must include: 

1. The name of the member
2. The member’s social security number
3. The group name or identification number
4. A statement in clear and concise terms of the reason or reasons for disagreement with the handling of the claim
5. Any material or information that the member has which indicates that the member is entitled to benefits under the plan

To appeal a post-service claim, submit your appeal in writing to our appeals resolution team:

Sana Benefits
Attn: Appeals
3723 Greenville Ave STE 13463
Dallas, TX 75206

To appeal a pre-service claim, submit your appeal in writing to our utilization review administrator: 

Valenz 
12802 Tampa Oak Boulevard 
Suite 330 
Tampa, FL 33637 
Phone: 877-608-2200 
Fax: 813-514-0607 
Email: carecustomerservice@valenzhealth.com

Once your written appeal is received, it will be reviewed, and an initial determination will be sent to you within the following timelines:

Pre-service Claims: Within 30 days from receipt of appeal
Urgent Pre-service Claims: Within 72 hours from receipt of appeal
Post-service Claims: Within 60 days from receipt of appeal