{
  "mailbox": {
    "email": "appeals-intake@mojavecrest.com",
    "name": "Mojave Crest Appeals Intake"
  },
  "contacts": [
    {
      "email": "ur@desertspringsrecovery.org",
      "name": "Utilization Review - Desert Springs Recovery Center"
    },
    {
      "email": "intake@canyonridgereview.com",
      "name": "Canyon Ridge"
    },
    {
      "email": "member.services@mojavecrest.com",
      "name": "Member Services - Mojave Crest Assurance Company"
    },
    {
      "email": "records@sunriseimaging.com",
      "name": "Radiology Records - Sunrise Imaging Center"
    }
  ],
  "folders": [
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      "name": "Active Appeals"
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    },
    {
      "name": "Archive/2026-Q1"
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  "emails": [
    {
      "email_id": "1",
      "folder": "INBOX",
      "subject": "Concurrent Care Appeal — Auth AUTH-2026-00441 — Termination 2026-04-16",
      "from_addr": "ur@desertspringsrecovery.org",
      "to_addr": "appeals-intake@mojavecrest.com",
      "cc_addr": null,
      "bcc_addr": null,
      "date": "2026-04-14T09:47:00-07:00",
      "message_id": "<AUTH-00441-appeal-20260414@desertspringsrecovery.org>",
      "in_reply_to": null,
      "body_text": "EXPEDITED CONCURRENT CARE APPEAL REQUEST\n\nTO: Mojave Crest Assurance Company Appeals & Grievances Department\nFROM: Utilization Review Department, Desert Springs Recovery Center\nDATE: April 14, 2026\nRE: Expedited Appeal - Concurrent Care Authorization Termination\n\n═══════════════════════════════════════════════════════════\nMEMBER AND AUTHORIZATION INFORMATION\n═══════════════════════════════════════════════════════════\n\nMember ID:               MBR-2026-04471\nGroup ID:                GRP-00892\nAuthorization ID:        AUTH-2026-00441\nClaim ID:                CLM-2026-03917\n\nAuthorized Service:      Inpatient Substance Use Disorder Residential Treatment\nFacility:                Desert Springs Recovery Center\nFacility NPI:            1497263850\n\nAdmission Date:          March 18, 2026\nStay Dates:              March 18, 2026 through present (ongoing)\nTotal Billed Charges:    $88,500.00 (to date)\n\n═══════════════════════════════════════════════════════════\nTERMINATION NOTICE DETAILS\n═══════════════════════════════════════════════════════════\n\nMCA Termination Notice Date:     April 13, 2026\nTermination Effective Date/Time: April 16, 2026 at 12:00 PM PT\nMedical Policy Cited:            MP-018-v2.1-20260101\n                                 (\"Residential SUD Treatment - Medical Necessity Criteria\")\n\n═══════════════════════════════════════════════════════════\nBASIS FOR APPEAL\n═══════════════════════════════════════════════════════════\n\nDesert Springs Recovery Center hereby submits an EXPEDITED APPEAL of the concurrent care authorization termination issued April 13, 2026, on the following grounds:\n\n1. CLINICAL APPROPRIATENESS\n   The member continues to meet medical necessity criteria for residential SUD treatment. Clinical deterioration and relapse risk remain elevated. Premature discharge poses immediate threat to member safety and treatment outcomes.\n\n2. MENTAL HEALTH PARITY VIOLATION\n   MCA's application of Medical Policy MP-018-v2.1 to residential SUD treatment imposes criteria that are MATERIALLY MORE RESTRICTIVE than those applied to comparable medical/surgical inpatient rehabilitation services, including:\n\n   • Stricter functional improvement timelines\n   • More rigid discharge-readiness benchmarks\n   • Higher burden of proof for continued stay justification\n   • Narrower recognition of co-occurring condition complexity\n\n   This differential standard violates:\n   - Mental Health Parity and Addiction Equity Act (MHPAEA), 42 U.S.C. § 300gg-26\n   - Nevada Revised Statutes § 695B.255 (Mental Health and Substance Use Disorder Parity)\n\n3. EXPEDITED REVIEW JUSTIFICATION\n   With termination effective April 16 at 12:00 PM PT (48 hours from receipt of this appeal), the member faces:\n   - Immediate loss of medically necessary care\n   - Unsafe discharge during critical treatment phase\n   - Increased relapse and hospitalization risk\n\n═══════════════════════════════════════════════════════════\nREQUEST\n═══════════════════════════════════════════════════════════\n\nDesert Springs Recovery Center respectfully requests:\n\n1. EXPEDITED concurrent care appeal review pursuant to NAC 695B.530\n2. Extension of authorization coverage pending appeal resolution\n3. Independent clinical review by qualified SUD specialist\n4. Parity compliance assessment of MP-018-v2.1 application\n\n\n═══════════════════════════════════════════════════════════\nTREATING PHYSICIAN CERTIFICATION OF EXPEDITED REVIEW NEED\n═══════════════════════════════════════════════════════════\n\nI, Dr. Marcus Odera, MD, FASAM, am the attending physician of record for\nthe member identified above (MBR-2026-04471) at Desert Springs Recovery\nCenter. I hereby certify, in writing, pursuant to 42 C.F.R. § 438.210 and\nNevada Administrative Code § 695B.530, that application of the standard\ninternal appeal review timeline would seriously jeopardize this member's\nlife, health, and ability to regain maximum function.\n\nClinical Basis for Expedited Certification:\nThe member is currently enrolled in medically necessary residential SUD\ntreatment. Authorization has been unilaterally terminated effective\nApril 16, 2026 at 12:00 PM PT. Premature discharge at this stage of\ntreatment presents a clinically documented and immediate risk of:\n\n  • Acute relapse with high-lethality overdose potential\n  • Medical decompensation secondary to abrupt withdrawal of structured\n    therapeutic support\n  • Inability to safely transition to a lower level of care within the\n    48-hour window imposed by MCA's termination notice\n\nThe member cannot safely wait the standard 30-day review window. Expedited\nreview is medically required. I request that Mojave Crest Assurance Company\nhonor this certification and process this appeal on an expedited basis\nimmediately.\n\nAttending Physician:     Dr. Marcus Odera, MD, FASAM\nMedical License (NV):    NV-MD-058847\nDirect Phone:            (760) 555-0149\nSignature Date:          April 14, 2026\n\n═══════════════════════════════════════════════════════════\nATTACHMENTS\n═══════════════════════════════════════════════════════════\n\n1. MCA Termination Notice (AUTH-2026-00441)\n2. Updated Clinical Progress Notes (through April 13, 2026)\n3. Provider Appeal Letter with Detailed Clinical Rationale\n\nPlease confirm receipt and provide anticipated timeline for expedited review.\n\nRespectfully submitted,\n\nUtilization Review Department\nDesert Springs Recovery Center\nNPI: 1497263850\nPhone: (760) 555-0147\nFax: (760) 555-0148\nur@desertspringsrecovery.org",
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    },
    {
      "email_id": "2",
      "folder": "INBOX",
      "subject": "Case Acknowledgment - CASE-2026-00086 - External Review Accepted",
      "from_addr": "intake@canyonridgereview.com",
      "to_addr": "appeals-intake@mojavecrest.com",
      "cc_addr": null,
      "bcc_addr": null,
      "date": "2026-04-12T14:22:00Z",
      "message_id": "<IRO-ACK-00086-20260412@canyonridgereview.com>",
      "in_reply_to": null,
      "body_text": "Mojave Crest Assurance Company Appeals & Grievances Department:\n\nThis correspondence confirms Canyon Ridge's receipt and acceptance of the following case for external review:\n\nCASE ID:           CASE-2026-00086\nMember ID:         MBR-2026-09341\nDate Forwarded:    April 10, 2026\nReview Type:       Standard External Review\nService Category:  Outpatient Diagnostic Imaging\n\nCASE STATUS:\n✓ Case file received complete\n✓ Clinical reviewer assigned\n✓ Review in progress\n\nExpected determination date: May 25, 2026\n\nNo additional information is required from Mojave Crest Assurance Company at this time. Canyon Ridge will notify all parties upon completion of the independent medical review.\n\nIf you have questions regarding this case, please reference CASE-2026-00086 in all correspondence.\n\nSincerely,\n\nCanyon Ridge\nCase Management Department\nPhone: (877) 555-0198\nintake@canyonridgereview.com\n\n---\nThis is an informational notice. No action is required.",
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    },
    {
      "email_id": "3",
      "folder": "INBOX",
      "subject": "Status Inquiry - CASE-2026-00088",
      "from_addr": "member.services@mojavecrest.com",
      "to_addr": "appeals-intake@mojavecrest.com",
      "cc_addr": null,
      "bcc_addr": null,
      "date": "2026-04-11T10:15:00Z",
      "message_id": "<MS-FWD-88-20260411@mojavecrest.com>",
      "in_reply_to": null,
      "body_text": "Appeals Intake Team,\n\nMember Services has received an inquiry from the member below requesting a status update on their pending appeal. Please see forwarded message:\n\n--- FORWARDED MESSAGE ---\nFrom: Member (MBR-2026-17203)\nReceived: April 11, 2026 9:47 AM\n\nHello,\n\nI submitted an appeal three weeks ago regarding the denial of my inpatient medical/surgical stay (Case # CASE-2026-00088). I haven't heard anything back and my doctor is asking when we can proceed.\n\nCan you please let me know what the status is and when I can expect a decision?\n\nThank you\n--- END FORWARDED MESSAGE ---\n\nCASE DETAILS:\nCase ID: CASE-2026-00088\nMember ID: MBR-2026-17203\nAppeal Received: March 21, 2026\nService: Inpatient Medical/Surgical Stay\n\nMember Services has logged this inquiry as an inbound contact (Ticket #MS-56721). No new appeal intake action is required.\n\nPlease provide status update when available so we can respond to member.\n\nThanks,\nMember Services Team\nMojave Crest Assurance Company",
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    },
    {
      "email_id": "4",
      "folder": "INBOX",
      "subject": "Supplemental Radiology Records - CASE-2026-00086",
      "from_addr": "records@sunriseimaging.com",
      "to_addr": "appeals-intake@mojavecrest.com",
      "cc_addr": null,
      "bcc_addr": null,
      "date": "2026-04-01T13:22:00Z",
      "message_id": "<SUPP-DOC-086-20260401@sunriseimaging.com>",
      "in_reply_to": null,
      "body_text": "Mojave Crest Assurance Company Appeals Department:\n\nRE: Supplemental Radiology Records Submission\n    CASE-2026-00086 / Member ID MBR-2026-09341\n\nPer your request dated March 31, 2026, Sunrise Imaging Center is providing supplemental documentation in support of the pending appeal for outpatient advanced imaging services (PET/CT Whole Body, CPT 78816).\n\nENCLOSED DOCUMENTATION:\n• Complete radiology interpretation report (March 5, 2026)\n• Ordering physician referral and clinical indication letter\n• Facility accreditation documentation (ACR)\n\nThese records should be appended to the existing case file for CASE-2026-00086. Please contact our records department at (702) 555-0214 if additional documentation is required.\n\nRadiology Records Department\nSunrise Imaging Center\nNPI: 1623847291\nPhone: (702) 555-0213\nFax: (702) 555-0214\nrecords@sunriseimaging.com",
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