Common use of Expedited External Review Clause in Contracts

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.