Common use of Additional Requirements for Expedited Internal Review of Adverse Determinations Clause in Contracts

Additional Requirements for Expedited Internal Review of Adverse Determinations.  In an expedited review, all information required by state law, as described in the Scope of Review section above, shall be transmitted between you and us by the most expeditious method available.  If an expedited review is conducted during a patient’s hospital stay or course of treatment, Health Care Services shall be continued without cost (except for applicable co-payments and deductibles) to you until we makes a final decision and notify you.  We shall not conduct an expedited review of an Adverse Determination made after Health Care Services have been provided to you. Notice of Internal Panel Decision  Notice required. Within the time period allotted for completion of its internal review, we shall notify you and the Practitioner/Provider of the internal review panel’s decision by telephone within twenty-four (24) hours of the panel’s decision and in writing or by electronic means within one (1) working day of the telephone notice.  Contents of notice. The written notice shall contain:  the names, titles, and qualifying credentials of the persons on the internal review panel,  a statement of the internal panel's understanding of the nature of the Grievance and all pertinent facts,  a description of the evidence relied on by the internal review panel in reaching its decision,  a clear and complete explanation of the rationale for the internal review panel's decision o The notice shall identify every provision of your Health Benefits Plan relevant to the issue of Coverage in the case under review, and explain why each provision did or did not support the panel’s decision regarding coverage of the requested Health Care Service. o The notice shall cite the Uniform Standards relevant to your medical condition and explain whether each supported or did not support the panel’s decision regarding the Medical Necessity of the requested Health Care Service.  notice of your right to request external review by the Superintendent, including the address and telephone number of the Managed Health Care Bureau of the Office of Superintendent of Insurance, a description of all procedures and time deadlines necessary to pursue external review, and copies of any forms required to initiate external review. This notice of your right to request external review is in addition to the same notice provided you in the Summary of Benefits and Coverage and Health Benefits Plan. External Review of Adverse Determinations

Additional Requirements for Expedited Internal Review of Adverse Determinations.  ⮚ In an expedited review, all information required by state law, as described in the Scope of Review section above, shall be transmitted between you and us by the most expeditious method available.  ⮚ If an expedited review is conducted during a patient’s hospital stay or course of treatment, Health Care Services shall be continued without cost (except for applicable co-payments and deductibles) to you until we makes a final decision and notify you.  ⮚ We shall not conduct an expedited review of an Adverse Determination made after Health Care Services have been provided to you. Notice of Internal Panel Decision  ⮚ Notice required. Within the time period allotted for completion of its internal review, we shall notify you and the Practitioner/Provider of the internal review panel’s decision by telephone within twenty-four (24) hours of the panel’s decision and in writing or by electronic means within one (1) working day of the telephone notice.  ⮚ Contents of notice. The written notice shall contain:  • the names, titles, and qualifying credentials of the persons on the internal review panel,  • a statement of the internal panel's understanding of the nature of the Grievance and all pertinent facts,  • a description of the evidence relied on by the internal review panel in reaching its decision,  • a clear and complete explanation of the rationale for the internal review panel's decision o The notice shall identify every provision of your Health Benefits Plan relevant to the issue of Coverage in the case under review, and explain why each provision did or did not support the panel’s decision regarding coverage of the requested Health Care Service. o The notice shall cite the Uniform Standards relevant to your medical condition and explain whether each supported or did not support the panel’s decision regarding the Medical Necessity of the requested Health Care Service.  • notice of your right to request external review by the Superintendent, including the address and telephone number of the Managed Health Care Bureau of the Office of Superintendent of Insurance, a description of all procedures and time deadlines necessary to pursue external review, and copies of any forms required to initiate external review. This notice of your right to request external review is in addition to the same notice provided you in the Summary of Benefits and Coverage and Health Benefits Plan. External Review of Adverse Determinations

Additional Requirements for Expedited Internal Review of Adverse Determinations.  In an expedited review, all information required by state law, as described in the Scope of Review section above, shall be transmitted between you and us by the most expeditious method available.  If an expedited review is conducted during a patient’s hospital stay or course of treatment, Health Care Services shall be continued without cost (except for applicable co-payments and deductibles) to you until we makes a final decision and notify you.  We shall not conduct an expedited review of an Adverse Determination made after Health Care Services have been provided to you. Notice of Internal Panel Decision  Notice required. Within the time period allotted for completion of its internal review, we shall notify you and the Practitioner/Provider of the internal review panel’s decision by telephone within twenty-four (24) hours of the panel’s decision and in writing or by electronic means within one (1) working day of the telephone notice.  Contents of notice. The written notice shall contain:  the names, titles, and qualifying credentials of the persons on the internal review panel,  a statement of the internal panel's understanding of the nature of the Grievance and all pertinent facts,  a description of the evidence relied on by the internal review panel in reaching its decision,  a clear and complete explanation of the rationale for the internal review panel's decision o The notice shall identify every provision of your Health Benefits Plan relevant to the issue of Coverage in the case under review, and explain why each provision did or did not support the panel’s decision regarding coverage of the requested Health Care Service. o The notice shall cite the Uniform Standards relevant to your medical condition and explain whether each supported or did not support the panel’s decision regarding the Medical Necessity of the requested Health Care Service.  notice of your right to request external review by the Superintendent, including the address and telephone number of the Managed Health Care Bureau of the Office of the Superintendent of Insurance, a description of all procedures and time deadlines necessary to pursue external review, and copies of any forms required to initiate external review. This notice of your right to request external review is in addition to the same notice provided you in the Summary of Benefits and Coverage and Health Benefits Plan. External Review of Adverse DeterminationsDeterminations  Right to external review. Every Grievant who is dissatisfied with the results of a medical panel review of an Adverse Determination by us and where applicable, with the results of a Grievance review by an entity that purchases or is authorized to purchase health care benefits pursuant to the New Mexico Health Care Purchasing Act, may request external review by the Superintendent at no cost to you. There shall be no minimum dollar amount of a claim before you may exercise this right to external review.  Exhaustion of internal appeals process. The Superintendent may require you to exhaust any Grievance procedures adopted by us or the entity that purchases Health Care Benefits pursuant to the New Mexico Health Care Purchasing Act, as appropriate, before accepting a Grievance for external review.