Common use of External Appeals Clause in Contracts

External Appeals. 1. The CMS Independent Review Entity (IRE) a. If, on internal Appeal, the Contractor does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS. For standard external Appeals, the IRE will send the Enrollee and the Contractor a letter with its decision within 30 calendar days after it receives the case from the Contractor, or at the end of up to a 14 calendar day extension. b. The CMS IRE must apply both the Medicare and MassHealth (which shall be considered supplemental services) definition for Medically Necessary Services when adjudicating the Enrollee’s Appeal for Medicare and supplemental services, and must decide based on whichever definition, or combination of definitions, provides a more favorable decision for the Enrollee. c. If the CMS IRE decides in the Enrollee’s favor and reverses the Contractor’s decision, the Contractor must authorize the service under dispute as expeditiously as the Enrollee’s health condition requires but no later than 72 hours from the date the Contractor receives the notice reversing the decision. d. For expedited external Appeals, the CMS IRE will send the Enrollee and the Contractor a letter with its decision within 72 hours after it receives the case from the Contractor, or at the end of up to a 14 calendar day extension. e. If the Contractor or the Enrollee disagrees with the IRE’s decision, further levels of Appeal are available, including a hearing before an Administrative Law Judge, a review by the Departmental Appeals Board, and judicial review. The Contractor must comply with any requests for information or participation from such further Appeal entities.