Common use of Expedited External Review Clause in Contracts

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 Insured’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 Insured. 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. 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 Insured or the Insured’s Authorized Representative and 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:  Insured;  Insured’s Physician;  Insured’s Authorized Representative, if any; and  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 Insured’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 Insured. 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. 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 Insured or the Insured’s Authorized Representative and 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:  • Insured;  • Insured’s Physician;  • Insured’s Authorized Representative, if any; and  • 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. The Insured may submit a request for an External Review of an adverse determination under this section only after the Insured has exhausted the internal SHL Appeals 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 Insured’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 Insured. 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. 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 Insured or the Insured’s Authorized Representative and 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:  Insured;  Insured’s Physician;  Insured’s Authorized Representative, if any; and  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 Insured’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 Insured. 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. 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 Insured or the Insured’s Authorized Representative and 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:  Insured;  Insured’s Physician; Agreement of Coverage  Insured’s Authorized Representative, if any; and  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 Insured’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 Insured. 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. 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 Insured or the Insured’s Authorized Representative and 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:  Insured;  Insured’s Physician;  Insured’s Authorized Representative, if any; and  SHL. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.