Department of Managed Health Care and Independent Medical Review Sample Clauses

Department of Managed Health Care and Independent Medical Review. If the Member wishes to pursue independent medical review the Member should complete the form which the Member will have received from the HMO and send it (in the envelope provided with the form and instructions) to the Department of Managed Health Care. The Department will review the Member’s request and determine whether the Member meets the criteria for independent medical review and therefore, is eligible for independent medical review. If the Department of Managed Health Care approves the Member’s request, the Member’s Appeal will be submitted to the Independent Medical Review Organization for review by a medical specialist, or a panel of medical specialists. The designated specialist or panel of specialists will make an independent determination of whether or not the care which is the subject of the Appeal is medically necessary. The Member will receive a copy of the independent medical review assessment of the Appeal. If the outcome of the independent medical review is that the care requested is medically necessary or does not qualify as Experimental and Investigative, the HMO will cover the provision of the health care services which were the subject of the Appeal. For non urgent cases, the independent medical review organization must provide its determination within 30 days of receiving the Member’s application and supporting documents. For cases which qualify for expedited review, the Independent Medical Review Organization must provide its determination within 3 business days. Upon notification of an independent medical review decision that the health care services under review are medically necessary, HMO will promptly take the actions necessary to comply with the decision.
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