Common use of Exhaustion of Process Clause in Contracts

Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to: 1. any investigation of a Complaint or Appeal by the Department of Insurance; or 2. the filing of a Complaint or Appeal with the Department of Insurance; or 3. the establishing of any litigation or arbitration, or any administrative proceeding regarding either any alleged breach of the Group Agreement or Certificate by HMO, or any matter within the scope of the Complaints and Appeals process. Under certain circumstances a Member may seek simultaneous review through the internal Appeals Procedure and External Review processes—these include Urgent Care Claims and situations where the Member is receiving an ongoing course of treatment. Exhaustion of the applicable process of the Appeal Procedure is not required under these circumstances.

Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to: 1. any investigation of a Complaint or Utilization Review Appeal by the Department of Insurance; or 2. the filing of a Complaint or Utilization Review Appeal with the Department of Insurance; or 3. the establishing of any litigation or arbitration, or any administrative proceeding regarding either any alleged breach of the Group Agreement or Certificate by HMO, or any matter within the scope of the Complaints and Appeals process. Under certain circumstances a Member may seek simultaneous review through the internal Appeals Procedure and External Review processes—processes – these include Urgent Care Claims and situations where the Member is receiving an ongoing course of treatment. Exhaustion of the applicable process of the Appeal Procedure is not required under these circumstances.

Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to: 1. any investigation of a Complaint or Appeal by the Department of Insurance; or 2. the filing of a Complaint or Appeal with the Department of Insurance; or 3. the establishing of any litigation or arbitration, or any administrative proceeding regarding either any alleged breach of the Group Agreement or Certificate by HMO, or any matter within the scope of the Complaints and Appeals process. Under certain circumstances a Member may seek simultaneous review through the internal Appeals Procedure and External Appeal to Independent Review Agency processes—these include Urgent Care Claims and situations where the Member is receiving an ongoing course of treatment. Exhaustion of the applicable process of the Appeal Procedure is not required under these circumstances.