Common use of Appeals of Adverse Benefit Determinations Clause in Contracts

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the HMO Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will provide an option to request an Appeal to Independent Review Agency. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 24 hours Review provided by HMO Appeals Committee. Within 15 calendar days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include important information including the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the noticenotice or after the receipt of notification of a benefit denied due to a contractual exclusion except a request for a Level One Appeal of an urgent care claim may also be oral. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) levels of Appeal of the adverse benefit determination. The Member must complete all steps in If the HMO Appeals process before bringing upholds an Adverse Benefit Determination at the First Level of Appeal, and the reason for the adverse determination was based on Medical Necessity, or experimental or investigational reasons, or a lawsuit against contractual exclusion and the HMO. A final adverse benefit determination notice will provide an option Member presents evidence for a medical professional that there is a reasonable medical basis that the exclusion does not apply to request the denied benefit, the Member or his/her authorized representative have the right to pursue an Appeal to Independent Review Agencyan independent utilization review organization (IURO), or file the voluntary Level Two Appeal. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the noticeHMO’s notice at the conclusion of the Level One Appeal explaining the Member’s right to make a Level Two Appeal. Any Member or Provider acting on behalf of a Member with the Member’s consent, who is dissatisfied with the results of a Level One Appeal, shall have the opportunity to pursue his or her Appeal before a panel of Physicians and/or other health care professionals with appropriate expertise who have not been involved in the Appeal and who has no direct financial interest in the Appeal or outcome of the review. The Member and/or an authorized representative may attend the Level Two Appeal hearing, question the representatives of HMO and present his/her case and any additional information the Member wishes. Upon request, the Member and HMO shall provide each other with any additional information that will be presented at the review. The information must be provided to both parties at least five days prior to the review. If new information becomes available after that five day period, such information may be presented as soon as possible. Within 10 business days of receipt of a Level Two Appeal, the HMO will acknowledge the The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; for persons with a physical or mental disability, create an imminent and substantial limitation on their existing ability to live independently; or, the opinion of the Physician with knowledge of the Member’s medical condition, would subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 24 hours Review provided by HMO Appeals Committee. Within 15 calendar days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing or by calling Member Services (see your identification card) within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the HMO Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will may provide an option to request an Appeal to Independent External Review Agency(if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 36 hours Review provided by HMO personnel not involved in making the adverse benefit determination. determination Within 24 -36 hours Review provided by HMO Appeals Committee. Review provided by HMO personnel not involved in making the adverse benefit determination or Level One Appeal decision. Within 15 calendar days Review provided by HMO personnel not involved in making the adverse benefit determination. .. Within 15 calendar days Review provided by HMO Appeals Committee. Review provided by HMO personnel not involved in making the adverse benefit determination or Level One Appeal decision.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice, or after the notification of a benefit denied due to a contractual exclusion except a request for a Level One Appeal of an Urgent Care claim may also be oral. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care Urgent Care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) of Appeal of the adverse benefit determination. The First Level Appeal shall be evaluated by a Physician who shall consult with an appropriate clinical peer or peers, unless the reviewing Physician is a clinical peer. The Physician and clinical peers shall not have been involved in the initial adverse benefit determination. A person who was previously involved with the denial may answer questions. All written denials of requests for Covered Benefits on the ground that such benefits are not Medically Necessary, appropriate, effective, or efficient shall be signed by a licensed Physician familiar with standards of care in Colorado. If the HMO upholds an adverse benefit determination at the first level of Appeal, and the reason for the adverse determination was based on Medical Necessity, or Experimental or Investigational reasons, or a contractual exclusion and the Member presents evidence for a medical professional that there is a reasonable medical basis that the exclusion does not apply to the denied benefit, the Member or his/her authorized representative have the right to pursue an Appeal to an independent utilization review organization (IURO), or file the voluntary Level Two Appeal. The Member must complete all steps in the HMO Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will provide an option to request an Appeal to Independent Review AgencyExternal Review. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the noticenotice at the conclusion of the Level One Appeal explaining the Member’s right to make a Level Two Appeal. Any Member or Provider acting on behalf of a Member with the Member’s consent, who is dissatisfied with the results of a Level One Appeal, shall have the opportunity to pursue their Appeal before a panel of Physicians and/or other health care professionals with appropriate expertise who have not been involved in the Appeal and who has no direct financial interest in the Appeal or outcome of the review. The Member and/or an authorized representative may attend the Level Two Appeal hearing, question the representatives of the HMO and present their case and any additional information the Member wishes. Upon request, the Member and the HMO shall provide each other with any additional information that will be presented at the review. The information must be provided to both parties at least 5 days prior to the review. If new information becomes available after that 5 day period, such information may be presented as soon as possible. Within 10 business days of receipt of a Level Two Appeal, the HMO will acknowledge the The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; for persons with a physical or mental disability, create an imminent and substantial limitation on their existing ablity to live independently; or, the opinion of the Physician with knowledge of the Member’s medical condition would subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 hours Review provided by Medical Director (when clinical peer) or the Medical Director in consultation with clinical peer HMO personnel not involved in making the adverse benefit determination. Within 24 hours Review provided by HMO Appeals Committee. Within 15 calendar days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for one; two level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the HMO Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will may provide an option to request an Appeal to Independent External Review Agency(if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 36 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 24 36 hours Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision. Within 15 calendar days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member However, Level One Appeals may also choose to have another person (an authorized representative) make the Appeal be requested orally. A Member, or a Provider acting on behalf of a Member and with the Member’s behalf by providing consent, dissatisfied with a utilization management adverse benefit determination will have the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the opportunity to Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) levels of Appeal of the adverse benefit determination. The Member must complete all steps in the two levels of HMO Appeals process review before pursuing an Appeal to an independent utilization review organization (IURO) or bringing a lawsuit against the HMO. A final adverse benefit determination notice , unless serious or significant harm to the Member has occurred or will provide an option to request an Appeal to Independent Review Agencyimminently occur. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the noticeHMO’s notice at the conclusion of the Level One Appeal explaining the Member’s right to make a Level Two Appeal. Within 10 business days of receipt of a Level Two Appeal, the HMO will acknowledge the Appeal in writing. The following chart summarizes some information about how Level One Appeal review will be conducted by a Physician who was not the Appeals are handled for different types of claims. Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health original reviewer nor a subordinate of the Member, original reviewer who rendered the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 hours Review provided by HMO personnel not involved in making the initial adverse benefit determination. Within 24 hours Review provided For a Level Two Appeal, the HMO will conduct a same or similar specialty review for Appeals involving clinical issues before a panel of Physicians and/or other health care professionals selected by HMO Appeals Committee. Within 15 calendar days Review provided by HMO personnel who have not been involved in making any of the adverse benefit determination. Within 15 calendar days Review provided by HMO Appeals Committeeprevious utilization management decisions.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the HMO Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will may provide an option to request an Appeal to Independent External Review Agency(if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 36 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 24 -36 hours Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision. Within 15 calendar days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision.