Common use of Expedited External Review Clause in Contracts

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimental, investigational or unproven, 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 MemberInsured’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, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  MemberInsured;  MemberInsured’s Physician; Agreement of Coverage  MemberInsured’s Authorized Representative, if any; and  HPNSHL. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  • if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimentalExperimental, investigational Investigational or unprovenUnproven, 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 MemberInsured’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, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  Member• Insured;  Member• Insured’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.;

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  • if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  • Member;  • Member’s Physician; Agreement of Coverage  • Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimentalExperimental, investigational Investigational or unprovenUnproven, 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 MemberInsured’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, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  MemberInsured;  MemberInsured’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.;

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  • if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  • Member;  • Member’s Physician; Agreement of Coverage  • Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may requestwithin 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 HPN SHL and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimental, investigational experimental or unproveninvestigational, and,  if the treating Provider 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 MemberInsured’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, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.eight

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may requestwithin 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 The Insured or the Insured’s Authorized Representative may request in writing, an internal Expedited appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimental, investigational experimental or unproveninvestigational, and,  if the treating Provider 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 MemberInsured’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, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.eight

Expedited External Review. The Member or the Member’s Authorized Representative may request, request in writing, an internal Expedited appeal Appeal by HPN and an Expedited External Review from OCHA simultaneously  • if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, and,  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 Member’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiatedOCHA. Upon receipt of such request and proof, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  • Member;  • Member’s Physician; Agreement of Coverage  • Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may request, request in writing, an internal Expedited appeal Appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  • if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimentalExperimental, investigational Investigational or unproven, Unproven and,  • if the treating Provider 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 MemberInsured’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiatedOCHA. Upon receipt of such request and proof, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

Expedited External Review. The only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: • Any medical records of the Member relating to the adverse determination; • A copy of the provisions of this Plan upon which the adverse determination was based; • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative may Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, in writingmodify, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  if or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the requested or recommended service or treatment is determined by HPN basis thereof, to be experimentalthe: • Member; • Member’s Physician; • Member’s Authorized Representative, investigational or unproven, and,  if the treating Provider certifies, in writing, that such service or treatment would be less effective if not promptly initiated. An oral any; and A request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of 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 OCHA that such service an inpatient facility; or treatment would be significantly less effective if not promptly initiated• failure to proceed in an expedited manner may jeopardize the life or health of the Member. Upon receipt of such request and proof, the The OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the approve or deny this request meets the requirements for Expedited External Review pursuant with seventy-two (72) hours after receipt of the above required proof. If OCHA approves the request, it shall assign the request to this section an IRO no later than one (1) business day after approving the request. HPN will supply all relevant medical documents and notify 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 the OCHA of the determination. If HPN determines the request agree to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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 determinationlonger 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; Agreement of Coverage  • Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimentalExperimental, investigational Investigational or unprovenUnproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may request, request in writing, an internal Expedited appeal Appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimental, investigational or unprovenunproven or investigational, and,  if the treating Provider 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 MemberInsured’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiatedOCHA. Upon receipt of such request and proof, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  MemberInsured;  MemberInsured’s Physician; Agreement of Coverage  MemberInsured’s Authorized Representative, if any; and  HPNSHL. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

Expedited External Review. The Member Insured or the MemberInsured’s Authorized Representative may request, request in writing, an internal Expedited appeal Appeal by HPN SHL and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN SHL to be experimental, investigational or unprovenunproven or investigational, and,  if the treating Provider 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 MemberInsured’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, the OCHA shall immediately notify HPN SHL accordingly. HPN SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member Insured or the MemberInsured’s Authorized Representative and the OCHA of the determination. If HPN SHL determines the request to be ineligible, the Member Insured will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPNSHL. The IRO has one (1) business day to select one or more clinical reviewers. HPN SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member Insured or MemberInsured’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 Member Insured or the MemberInsured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member Insured or the MemberInsured’s Authorized Representative must be submitted to HPN 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:  MemberInsured;  MemberInsured’s Physician; Agreement of Coverage  MemberInsured’s Authorized Representative, if any; and  HPNSHL. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

Expedited External Review. The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an Expedited External Review from OCHA simultaneously  • if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimentalExperimental, investigational Investigational or unprovenUnproven, 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 Member’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, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  • Member;  • Member’s Physician; Agreement of Coverage  • Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and

Expedited External Review. The Member or the Member’s Authorized Representative may request, request in writing, an internal Expedited appeal Appeal by HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by HPN to be experimental, investigational or unproven, and, 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 Member’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiatedOCHA. Upon receipt of such request and proof, the OCHA shall immediately notify HPN accordingly. HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to be ineligible, the Member will be notified that the request may be appealed to XXXXOCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Member or Member’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 Member or the Member’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the Member’s Authorized Representative must be submitted to HPN 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:  Member;  Member’s Physician; Agreement of Coverage  Member’s Authorized Representative, if any; and  HPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.and