Common use of Expedited Appeal – 1st Level Formal Appeal Clause in Contracts

Expedited Appeal – 1st Level Formal Appeal. The Insured can ask (either orally or in writing) for an Expedited Appeal of an Adverse Benefit Determination for a Pre-Service Claim that involves an Urgent Care Claim if the Insured or his Physician believe that the health of the Insured could be seriously harmed by waiting for a routine appeal decision. Expedited Appeals are not available for appeals regarding denied claims for benefit payment (Post-Service Claim) or for Pre-Service Claims that are not Urgent Care Claims. Expedited Appeals must be decided no later than seventy-two (72) hours after receipt of the appeal, provided all necessary information has been submitted to SHL. If the initial notification was oral, SHL shall provide a written or electronic explanation to the Insured within seventy-two (72) hours after the expedited appeal being filed. If insufficient information is received, SHL shall notify the Insured as soon as possible, but no later than twenty-four (24) hours after receipt of the claim of the specific information necessary to complete the claim. The Insured will be afforded a reasonable amount of time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specified information. SHL shall notify the Insured of the benefit determination as soon as possible, but in no case later than forty-eight (48) hours after the earlier of:  SHL’s receipt of the specified information, or  The end of the period afforded the Insured to provide the specified information. If the Insured’s Physician requests an Expedited Appeal, or supports a Insured’s request for an Expedited Appeal, and indicates that waiting for a routine appeal could seriously harm the health of the Insured or subject the Insured to unmanageable severe pain that cannot be adequately managed without care or treatment that is the subject of the Claim for Benefits, SHL will automatically grant an Expedited Appeal. If a request for an Expedited Appeal is submitted without support of the Insured’s Physician, SHL shall decide whether the Insured’s health requires an Expedited Appeal. If an Expedited Appeal is not granted, SHL will provide a decision within thirty (30) days, subject to the routine appeals process for Pre-Service Claims.

Expedited Appeal – 1st Level Formal Appeal. The Insured Member can ask (either orally or in writing) for an Expedited Appeal of an Adverse Benefit Determination for a Pre-Service Claim that involves an Urgent Care Claim if the Insured Member or his Physician believe that the health of the Insured Member could be seriously harmed by waiting for a routine appeal decision. Expedited Appeals are not available for appeals regarding denied claims for benefit payment (Post-Service Claim) or for Pre-Service Claims that are not Urgent Care Claims. Expedited Appeals must be decided no later than seventy-two (72) hours after receipt of the appeal, provided all necessary information has been submitted to SHLHPN. If the initial notification was oral, SHL HPN shall provide a written or electronic explanation to the Insured Member within seventy-two (72) hours after the expedited appeal being filed. If insufficient information is received, SHL HPN shall notify the Insured Member as soon as possible, but no later than twenty-four (24) hours after receipt of the claim of the specific information necessary to complete the claim. The Insured Member will be afforded a reasonable amount of time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specified information. SHL HPN shall notify the Insured Member of the benefit determination as soon as possible, but in no case later than forty-eight (48) hours after the earlier of:  SHLHPN’s receipt of the specified information, or  The end of the period afforded the Insured Member to provide the specified information. If the InsuredMember’s Physician  requests an Expedited Appeal, or  supports a InsuredMember’s request for an Expedited Appeal, and indicates that waiting for a routine appeal could seriously harm the health of the Insured Member or subject the Insured Member to unmanageable severe pain that cannot be adequately managed without care or treatment that is the subject of the Claim for Benefits, SHL HPN will automatically grant an Expedited Appeal. If a request for an Expedited Appeal is submitted without support of the InsuredMember’s Physician, SHL HPN shall decide whether the InsuredMember’s health requires an Expedited Appeal. If an Expedited Appeal is not granted, SHL HPN will provide a decision within thirty (30) days, subject to the routine appeals process for Pre-Service Claims.

Expedited Appeal – 1st Level Formal Appeal. The Insured can ask (either orally or in writing) for an Expedited Appeal of an Adverse Benefit Determination for a Pre-Service Claim that involves an Urgent Care Claim if the Insured or his Physician believe that the health of the Insured could be seriously harmed by waiting for a routine appeal decision. Expedited Appeals are not available for appeals regarding denied claims for benefit payment (Post-Service Claim) or for Pre-Service Claims that are not Urgent Care Claims. Expedited Appeals must be decided no later than seventy-two (72) hours after receipt of the appeal, provided all necessary information has been submitted to SHL. If the initial notification was oral, SHL shall provide a written or electronic explanation to the Insured within seventy-two (72) hours after the expedited appeal being filed. If insufficient information is received, SHL shall notify the Insured as soon as possible, but no later than twenty-four (24) hours after receipt of the claim of the specific information necessary to complete the claim. The Insured will be afforded a reasonable amount of time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specified information. SHL shall notify the Insured of the benefit determination as soon as possible, but in no case later than forty-eight (48) hours after the earlier of:  • SHL’s receipt of the specified information, or  The • the end of the period afforded the Insured to provide the specified information. If the Insured’s Physician Physician: • requests an Expedited Appeal, or • supports a an Insured’s request for an Expedited Appeal, and indicates that waiting for a routine appeal could seriously harm the health of the Insured or subject the Insured to unmanageable severe pain that cannot be adequately managed without care or treatment that is the subject of the Claim for Benefits, SHL will automatically grant an Expedited Appeal. If a request for an Expedited Appeal is submitted without support of the Insured’s Physician, SHL shall decide whether the Insured’s health requires an Expedited Appeal. If an Expedited Appeal is not granted, SHL will provide a decision within thirty (30) days, subject to the routine appeals process for Pre-Service Claims.

Expedited Appeal – 1st Level Formal Appeal. The Insured Member can ask (either orally or in writing) for an Expedited Appeal of an Adverse Benefit Determination for a Pre-Service Claim that involves an Urgent Care Claim if the Insured Member or his Physician believe that the health of the Insured Member could be seriously harmed by waiting for a routine appeal decision. Expedited Appeals are not available for appeals regarding denied claims for benefit payment (Post-Service Claim) or for Pre-Service Claims that are not Urgent Care Claims. Expedited Appeals must be decided no later than seventy-two (72) hours after receipt of the appeal, provided all necessary information has been submitted to SHLHPN. If the initial notification was oral, SHL HPN shall provide a written or electronic explanation to the Insured Member within seventy-two (72) hours after the expedited appeal being filed. If insufficient information is received, SHL HPN shall notify the Insured Member as soon as possible, but no later than twenty-four (24) hours after receipt of the claim of the specific information necessary to complete the claim. The Insured Member will be afforded a reasonable amount of time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specified information. SHL HPN shall notify the Insured Member of the benefit determination as soon as possible, but in no case later than forty-eight (48) hours after the earlier of:  SHL• HPN’s receipt of the specified information, or  • The end of the period afforded the Insured Member to provide the specified information. If the InsuredMember’s Physician • requests an Expedited Appeal, or • supports a InsuredMember’s request for an Expedited Appeal, and indicates that waiting for a routine appeal could seriously harm the health of the Insured Member or subject the Insured Member to unmanageable severe pain that cannot be adequately managed without care or treatment that is the subject of the Claim for Benefits, SHL HPN will automatically grant an Expedited Appeal. If a request for an Expedited Appeal is submitted without support of the InsuredMember’s Physician, SHL HPN shall decide whether the InsuredMember’s health requires an Expedited Appeal. If an Expedited Appeal is not granted, SHL HPN will provide a decision within thirty (30) days, subject to the routine appeals process for Pre-Service Claims.