External exception request review Sample Clauses
The "External exception request review" clause establishes a process for handling requests that fall outside the standard terms of an agreement by requiring review from an external party or committee. Typically, this means that if a party seeks an exception to a contractual obligation or policy, the request must be formally submitted and evaluated by an independent reviewer or designated third party, who will assess the merits and potential impacts of granting the exception. This clause ensures that exceptions are considered objectively and consistently, reducing the risk of arbitrary decisions and promoting fairness in the administration of the contract.
External exception request review. If we deny a request for a standard exception or for an expedited exception, the member, the member’s designee or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. We will make our determination on the external exception request and notify the member, the member’s designee or the member’s prescribing physician of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception. If we grant an external exception review of a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the exigency. Notice and Proof of Loss: In order to obtain payment for covered service expenses incurred at a pharmacy for prescription orders, a notice of claim and proof of loss must be submitted directly to us. Non-Covered Services and Exclusions: No benefits will be paid under this benefit subsection for services provided or expenses incurred:
1. For prescription drugs for the treatment of erectile dysfunction or any enhancement of sexual performance unless listed on the formulary.
2. For immunization agents, blood, or blood plasma, except when used for preventative care and listed on the formulary.
3. For medication that is to be taken by the member, in whole or in part, at the place where it is dispensed.