EXTERNAL APPEAL PROCEDURE Sample Clauses
The External Appeal Procedure clause establishes a formal process for disputing decisions made by an organization, typically regarding claims or benefits, by allowing an independent third party to review the case. In practice, this clause outlines the steps a claimant must follow to initiate an external appeal, such as submitting required documentation within a specified timeframe and cooperating with the review entity. Its core function is to provide an impartial mechanism for resolving disputes, ensuring fairness and transparency beyond the organization's internal processes.
EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 5 Inpatient Hospital Services B–24 6 Skilled Nursing Facility Services B–27 7 Home Health Care Services B–29 8 Hospice Care Services B–32 9 Mental Health and Substance Use Disorder Services B–34 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–39 12 Prescription Drugs B–43 13 Care Support Programs B–45 14 General Provisions B–46 15 Exclusions and Limitations B–52 SAMPLE