Denial of Level I Appeal Sample Clauses

Denial of Level I Appeal. If we deny your Level I Appeal, we will give you a written decision, which will include the following:

Denial of Level I Appeal. If we deny your Level I Appeal, we will give you a written decision, which will include the following: i. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; ii. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; iii. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; iv. The title and qualifications of the person who conducted the review; v. A description of any additional material or information necessary for the covered person to perfect the claim and an explanation as to why such material is necessary; vi. How to obtain a second level review; vii. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 0-000-000-0000 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and viii. A statement describing all other dispute resolution options available to you, including any further internal review and options or external review and legal actions. If the Appeal involves an Adverse Determination, a copy of the notice of the right to external review and an explanation of how to request external review will be provided.

Denial of Level I Appeal. If we deny your Level I Appeal, we will give you a written decision, which will include the following: i. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; ii. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; iii. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost;