Common use of Expedited External Review Clause in Contracts

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. 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. A request for an Expedited External Review may be submitted to OCHA after it receives proof from the MemberInsured’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 MemberInsured. The OCHA shall approve or deny this request for Expedited External Review within with 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 SHL 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 Insured or the MemberInsured’s Authorized Representative and HPN SHL 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• Insured;  Member• Insured’s Physician;  MemberAgreement of Coverage • Insured’s Authorized Representative, if any; andand • SHL. 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. A request for an Expedited External Review may be submitted to OCHA when the mandatory 1st Level Appeal has been exhausted and after it receives proof from the MemberInsured’s Provider that the adverse determination concerns:  An • 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 MemberInsured. 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 SHL 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 Insured or the MemberInsured’s Authorized Representative and HPN SHL 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• Insured;  Member• Insured’s Physician;  Member• Insured’s Authorized Representative, if any; andand • SHL. 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. A request for an Expedited External Review may be submitted to OCHA when the mandatory 1st Level Appeal has been exhausted and 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. A request for an Expedited External Review may be submitted to OCHA when the mandatory 1st Level Appeal has been exhausted and 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