Common use of Expedited Appeals Clause in Contracts

Expedited Appeals. If you are appealing an Adverse Decision that involves an Urgent Medical Condition, you may request an expedited decision by contacting Health Plan: During Regular Business Hours Monday through Friday from 7:30am – 5:30pm – The Member should contact the Member Services Department. Inside the Washington, D.C. Metropolitan area (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000. During Non-Business Hours The Member should call the Advice/Appointment Line. Inside the Washington, D.C. Metropolitan area (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Once an expedited appeal is initiated, clinical review will determine if the appeal involves an Urgent Medical Condition. If the appeal does not meet the criteria for an expedited appeal, the request will be managed as a formal appeal, as described above. If such a decision is made, Health Plan will call the Member within 24 hours. If the request for appeal meets the criteria for an expedited appeal, the appeal will be reviewed by a Plan Physician who is board certified or eligible in the same specialty as the treatment under review, and who is not the individual (or the individual’s subordinate) who made the initial adverse decision. If additional information is needed to proceed with the review, the Member or the Authorized Representative will be contacted by telephone or facsimile. Expedited Appeal Decisions An expedited appeal will be concluded as soon as possible after receipt of all necessary documentation by Health Plan, but not later than 24 hours after receipt of the request for appeal. Health plan will notify you of its decision immediately by telephone. If the Service is approved, Health Plan will provide assistance in arranging the authorized Service. If the Service is denied, written notice of its decision will be sent within one business day after that. Notification of Adverse Appeal Decisions If the review results in a denial, Health Plan will notify the Member and the Authorized Representative in writing. The notification shall include:

Expedited Appeals. If you are appealing an Adverse Decision that involves an Urgent Medical Condition, you may request an expedited decision by contacting Health Plan: During Regular Business Hours Monday through though Friday from 7:30am – 5:30pm – The Member should contact the Member Services Department. Inside the Washington, D.C. Metropolitan area (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000. During Non-Business Hours The Member should call the Advice/Appointment Line. Inside the Washington, D.C. Metropolitan area (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Once an expedited appeal is initiated, clinical review will determine if the appeal involves an Urgent Medical Condition. If the appeal does not meet the criteria for an expedited appeal, the request will be managed as a formal appeal, as described above. If such a decision is made, Health Plan will call the Member within 24 hours. If the request for appeal meets the criteria for an expedited appeal, the appeal will be reviewed by a Plan Physician who is board certified or eligible in the same specialty as the treatment under review, and who is not the individual (or the individual’s subordinate) who made the initial adverse decision. If additional information is needed to proceed with the review, the Member or the Authorized Representative will be contacted by telephone or facsimile. Expedited Appeal Decisions An expedited appeal will be concluded as soon as possible after receipt of all necessary documentation by Health Plan, but not later than 24 hours after receipt of the request for appeal. Health plan will notify you of its decision immediately by telephone. If the Service is approved, Health Plan will provide assistance in arranging the authorized Service. If the Service is denied, written notice of its decision will be sent within one business day after that. Notification of Adverse Appeal Decisions If the review results in a denial, Health Plan will notify the Member and the Authorized Representative in writing. The notification shall include: