Common use of Agreement of Coverage Clause in Contracts

Agreement of Coverage. or a family member of a Member or the Member’s treating provider only when the Member is unable to provide consent. Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN will provide the Member notice of such an adverse determination which will include the following statement: HPN has denied your request for the provision or payment of a requested healthcare service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested, by submitting a request for External Review to the Office for Consumer Health Assistance. Additionally, as per applicable law and regulations, the notice will provide the Member the information outlined herein as well as the following: • The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state in which the Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, • and any other forms as required by Nevada law or regulation. The Member or the Member’s Authorized Representative may submit a request directly to OCHA for an External Review of an adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member or the Member’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Office for Consumer Health Assistance 0000 X. Xxxxxx Xxx., Xxxxx 000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website xxx.XXX@xxxxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

Agreement of Coverage. 12.3 External Review HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person: • to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; • or a person authorized by law to provide substituted consent for a Member; • or a family member of a Member or the Member’s treating provider only when the Member is unable to provide consent. Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN will provide the Member notice of such an adverse determination which will include the following statement: HPN has denied your request for the provision or payment of a requested healthcare service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested, by submitting a request for External Review to the Office for Consumer Health Assistance. Additionally, as per applicable law and regulations, the notice will provide the Member the information outlined herein as well as the following: • The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state in which the Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, • and any other forms as required by Nevada law or regulation. The Member or the Member’s Authorized Representative may submit a request directly to OCHA for an External Review of an adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member or the Member’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Office for Consumer Health Assistance 0000 3320 X. Xxxxxx Xxx., Xxxxx 000 Xxx Xxxxx XX 00000 Xxs Vegas NV 89102 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website xxx.XXX@xxxxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

Agreement of Coverage. 13.3 External Review SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family member Insured of a Member an Insured or the MemberInsured’s treating provider only when the Member Insured is unable to provide consent. Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN SHL will provide the Member Insured notice of such an adverse determination which will include the following statement: HPN SHL has denied your request for the provision or payment of a requested healthcare service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested, requested by submitting a request for External Review to the Office for Consumer Health Assistance. Additionally, as per applicable law and regulations, the notice will provide the Member Insured the information outlined herein as well as the following: • The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state in which the Member Insured resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member Insured or the MemberInsured’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Member Insured or the MemberInsured’s Authorized Representative can authorize HPN SHL and the MemberInsured’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, • and any other forms as required by Nevada law or regulation. The Member Insured or the MemberInsured’s Authorized Representative may submit a request directly to OCHA for an External Review of an adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member Insured or the MemberInsured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Office for Consumer Health Assistance 0000 X. Xxxxxx Xxx., Xxxxx 000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website xxx.XXX@xxxxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member Insured of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN SHL shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPNSHL.

Agreement of Coverage. 13.3 External Review SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family member Insured of a Member an Insured or the MemberInsured’s treating provider only when the Member Insured is unable to provide consent. Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN SHL will provide the Member Insured notice of such an adverse determination which will include the following statement: HPN SHL has denied your request for the provision or payment of a requested healthcare service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested, requested by submitting a request for External Review to the Office for Consumer Health Assistance. Additionally, as per applicable law and regulations, the notice will provide the Member Insured the information outlined herein as well as the following: •  The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state in which the Member Insured resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member Insured or the MemberInsured’s Authorized Representative will also include •  a HIPAA compliant authorization form by which the Member Insured or the MemberInsured’s Authorized Representative can authorize HPN SHL and the MemberInsured’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, •  and any other forms as required by Nevada law or regulation. The Member Insured or the MemberInsured’s Authorized Representative may submit a request directly to OCHA for an External Review of an adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member Insured or the MemberInsured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Office for Consumer Health Assistance 0000 X. Xxxxxx Xxx., Xxxxx 000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website xxx.XXX@xxxxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member Insured of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN SHL shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPNSHL.