Common use of Appeal Review Clause in Contracts

Appeal Review. Each formal Appeal will be reviewed by a health care professional selected by the Health Plan based upon the specific issued presented in the Appeal, and who was not involved in the initial Adverse Decision. If the review requires medical expertise, the reviewer or panel will include at least one medical reviewer in the same specialty as the matter at issue. Each medical reviewer shall be a physician or an advanced practice registered nurse or other health care provider possessing a non-restricted license to practice or provide care anywhere in the United States, and have no history of disciplinary action or sanctions pending or taken against them by any governmental or professional regulatory body.

Appeal Review. Each formal Appeal appeal will be reviewed by a health care professional selected by the Health Plan based upon the specific issued presented in the Appealappeal, and who was not involved in the initial Adverse Decision. If the review requires medical expertise, the reviewer or panel will include at least one medical reviewer in the same specialty as the matter at issue. Each medical reviewer shall be a physician or an advanced practice registered nurse or other health care provider possessing a non-restricted license to practice or provide care anywhere in the United States, and have no history of disciplinary action or sanctions pending or taken against them by any governmental or professional regulatory body.