Expedited External Review Sample Clauses
Expedited External Review. If you have a medical condition where the timeframe for completion of (a) an expedited internal review of an appeal involving an Adverse Determina tion; (
Expedited External Review. The Insured or the Insured’s Authorized Representative may request in writing, an internal Expedited Appeal by SHL and an Expedited External Review from OCHA simultaneously if the adverse determination of the requested or recommended service or treatment is determined by SHL to be experimental, investigational or unproven or investigational, and, if the treating provider certifies, in writing, that such service or treatment would be less effective if not promptly initiated. An oral request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of proof from the Insured’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiated. Upon receipt of such request and proof, OCHA shall immediately notify SHL accordingly. SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured or the Insured’s Authorized Representative and OCHA of the determination. If SHL determines the request to be ineligible, the Insured will be notified that the request may be appealed to OCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHL. The IRO has one (1) business day to select one or more clinical reviewers. SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured or Insured’s Authorized Representative may, within five (5) business days after receiving notice of the assigned IRO, submit any additional information in writing to the IRO. Any information submitted by the Insured or the Insured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured or the Insured’s Authorized Representative must be submitted to SHL by the IRO within one (1) business day. The clinical reviewers have no more than five (5) days to provide an opinion to the IRO. The IRO has forty-eight (48) hours to review the opinion of the clinical reviewers and make a determination. The IRO shall notify the following parties no later than twenty-four (24) hours after completing its External Review: Insured; Insured’s Physician; Insured’s Authorized Representati...
Expedited External Review. A request for an Expedited External Review may be submitted to OCHA after it receives proof from the Member’s Provider that the adverse determination concerns: An inpatient admission; availability of inpatient care; continued stay or health care service for Emergency Services while still admitted to an inpatient facility; or failure to proceed in an expedited manner may jeopardize the life or health of the Member. The OCHA shall approve or deny this request for Expedited External Review within seventy-two (72) hours after receipt of the above required proof. If OCHA approves the request, it shall assign the request to an IRO no later than one (1) business day after approving the request. HPN will supply all relevant medical documents and information used to establish the adverse determination to the IRO within twenty-four (24) hours after receiving notice from the OCHA. The IRO shall complete its Expedited External Review within forty-eight (48) hours after initially being assigned the case unless the Member or the Member’s Authorized Representative and HPN agree to a longer time period. The IRO shall notify the following parties no later than twenty-four (24) hours after completing its Expedited External Review: Member; Member’s Physician; Member’s Authorized Representative, if any; and
Expedited External Review. (Applies to Urgent Care Claims only) If the initial decision of the Plan or the denial resulting from the Plan’s Internal Appeal Process involves an Urgent Care Claim, a Member or health care Provider on behalf of the Member may request an expedited external review of the Plan’s decision. Requests for expedited external review are subject to review by the Plan to determine whether they are timely, complete and eligible for external review. When the request involves a denied Urgent Care Claim, the Plan must complete the preliminary review and provide notice of its eligibility determination immediately upon receipt of the request for expedited external review. If the request is eligible for expedited external review, the Plan must then transmit all necessary documents and information that was considered in denying the Urgent Care Claim involved to an assigned IRO in an expeditious manner. The assigned IRO will conduct the review and provide notice of its final external review decision as expeditiously as the Member’s medical condition or circumstances require, but in no event more than seventy-two (72) hours following receipt by the IRO of the request for expedited external review. If notice of the decision by the IRO is not provided in writing, the IRO must provide within forty-eight (48) hours following initial notice of its final external review decision written confirmation of that decision to the Plan and the Member, or health care Provider filing the expedited external review request on behalf of the Member.
Expedited External Review. An expedited external review is similar to a standard external review, except with certain shorter time periods, and the timeframe for you or your provider to submit additional information to the IRO is eliminated. In some instances you may file an expedited external review before completing the internal appeals process. You may make a written or verbal request for an expedited external review if you receive either (i) an adverse benefit determination of a claim or appeal if the adverse benefit determination involves a medical condition for which, in the opinion of your prescriber, the time frame for completion of an expedited internal appeal would seriously jeopardize the life or health of the participant or would jeopardize the participant’s ability to regain maximum function and you have filed a request for an expedited internal appeal; or (ii) a final appeal decision, if the determination, in the opinion of your prescriber, involves a medical condition where the time frame for completion of a standard external review would seriously jeopardize the life or health of the participant or would jeopardize the participant’s ability to regain maximum function, or if the final appeal decision concerns an admission, availability of care, continued stay, or prescription drug product or service for which the participant received emergency services, but has not been discharged from a facility. Immediately upon receipt of the request, MedTrak will determine whether the participant (i) was covered under the Plan at the time the prescription drug product or service that is at issue in the request was provided; and (ii) has provided all the information and forms required so that MedTrak may process the request. After completing the review, MedTrak will immediately assign an IRO in the same manner MedTrak utilizes to assign standard external reviews to IROs. The IRO will determine if the matter contains an issue involving medical judgment and, upon a determination that a request is eligible for expedited external review. MedTrak will provide all necessary documents and information considered in making the determination to the assigned IRO. The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the same type of information and documents considered in a standard external review. In reaching a decision, the IRO will review the claim without regard to any decisions or conclusions reached by MedTrak. The IRO w...
Expedited External Review. An expedited external review is similar to a standard external review. The main difference between the two is that the time periods for completing certain portion of the review process are much shorter for the expedited external review, and if both you and UnitedHealthcare agree, you may file an expedited external review before completing the internal appeals process. You or your authorized representative may request an expedited external review with the Commissioner at the time you receive:
Expedited External Review. If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative can request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you or your representative of our determination within 24 hours following receipt of the request. You are responsible for paying the Annual Deductible stated in the Schedule of Benefits which is attached to your Policy before Benefits for Prescription Drug Products under this Policy are available to you unless otherwise allowed under your Policy. Benefits for PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Benefits for diabetes test strips will be exempt from Co-payment, deductible, and/or Co-insurance. You can obtain up to twelve cycles of a contraceptive at one time. Each cycle is no less than a one-month supply. You are responsible for paying the applicable Co-payment and/or Co-insurance described in the Benefit Information table. You are not responsible for paying a Co-payment and/or Co-insurance for PPACA Zero Cost Share Preventive Care Medications. The Co-payment amount or Co-insurance percentage you pay for a Prescription Drug Product will not exceed the Usual and Customary Charge of the Prescription Drug Product. The amount you pay for any of the following under your Policy will not be included in calculating any Out-of-Pocket Limit stated in your Policy: • Any non-covered drug product. You are responsible for paying 100% of the cost (the amount the pharmacy charges you) for any non-covered drug product. Our contracted rates (our Prescription Drug Charge) will not be available to you. NOTE: When Covered Health Care Services are provided by an Indian Health Service provider, your cost share may be reduced. Payment Term And Description Amounts Co-payment Co-payment for a Prescription Drug Product at a Network Pharmacy is a specific dollar amount. Co-insurance Co-insurance for a Prescription Drug Product at a Network Pharmacy is a percentage of the Prescription Drug Charge. Special Programs: We will have certain programs in which you will receive a reduced Co-payment and/or Co- insurance based on your actions such as adherence/compliance to medication or treatment regimens, and/or participation in health management programs. You can access information on these programs by ...
Expedited External Review. A member or a member’s authorized representative may file a request for an expedited external review with the Director either orally or in writing:
Expedited External Review. The Insured or Insured’s Authorized Representative may within four (4) months after receiving notice of an adverse determination subject to this section, submit a request to the OCHA for an External Review. OCHA will notify SHL and/or any other interested parties within one (1) business day after the receipt of the request for External Review. Within five (5) business days after SHL receives such notice and, subject to applicable Nevada law and regulation and pursuant to this section, SHL will make a preliminary determination of whether the case is complete and eligible for External Review according to Nevada law and regulations. Within one (1) business day of making such a determination, SHL will notify in writing, the Insured or the Insured’s Authorized Representative and OCHA, accordingly. If SHL determines that the case is incomplete and/or ineligible, SHL will notify the Insured in writing of such determination. Such notice shall include the required additional information or materials needed to make the request complete and, if applicable, state the reasons for ineligibility and also state that such determination may be appealed to OCHA. Upon appeal, OCHA may overturn SHL’s determination that a request for External Review of an adverse determination is ineligible, and submit the request to External Review, subject to all of the terms and provisions of this Plan and applicable Nevada law and regulation. Within one (1) business day after receiving the confirmation of eligibility for External Review from SHL, OCHA will assign the IRO accordingly and notify in writing the Insured or the Insured’s Authorized Representative and SHL that the request is complete and eligible for External Review and provide the name of the assigned IRO. SHL, within five (5) days after receipt of such notice from the OCHA, will supply all relevant medical documents and information used to establish the adverse determination to the assigned IRO who will select and assign one or more clinical reviewers to the External Review. The IRO shall approve, modify, or reverse the adverse determination pursuant to this section within twenty (20) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the: • Insured; • Insured’s Physician; The Insured or the Insured’s Authorized Representative may request in writing, an internal Expedited appeal by SHL and an Expedited External Review fr...
Expedited External Review. An expedited External Review may be requested at the same time a claimant requests an expedited internal appeal (1.c., above) of an Adverse Benefit Determination concerning:
1) an Urgent Care Claim; or
2) a denial on the basis that the requested service or treatment is Investigative, if the Covered Person’s Treating Physician certifies in writing that the service or treatment would be significantly less effective if not promptly initiated. However, the claimant must first exhaust the internal appeal process, unless otherwise waived by BCBSNE or directed by the IRO, consistent with state law. An expedited External Review may also be requested following a Final Internal Adverse Benefit Determination, if:
1) the Covered Person has a medical condition where the timeframe for completion of a standard External Review, as described in paragraph 3.a., above, would seriously jeopardize the life or health of the Covered Person or would jeopardize his or her ability to regain maximum function; or
2) the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care service for which the claimant has received emergency services, but has not been discharged from a facility; or
3) the Final Internal Adverse Benefit Determination is based on a determination that the requested service or treatment is Investigative, if the Covered Person’s Treating Physician certifies in writing that the service or treatment would be significantly less effective if not promptly initiated. The process for coordination of the expedited request between the NDOI, BCBSNE and the IRO, as described above for a standard review, will be done promptly upon receipt, by telephone, facsimile, or the most expeditious manner available. An expedited External Review decision shall be made by the IRO within 72 hours after receipt of the request. If notification of the decision to the claimant and BCBSNE was not in writing, the IRO will provide the decision in writing within 48 hours after the oral notification. An Expedited External Review is not available for retrospective Adverse or Final Adverse Benefit Determinations.