Common use of External Medical Appeal and Rescission of Coverage Clause in Contracts

External Medical Appeal and Rescission of Coverage. For medical Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with Us and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees with the internal medical Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four (4) months of receipt of the internal medical Appeal decision or Rescission of Coverage. Requests submitted to Us after four (4) months of receipt of the internal medical Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal medical Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of Our receipt of the External Appeal. The IRO will notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and Us for purposes of determining coverage under a health Contract. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary or Investigational, except to the extent that other remedies are available under State or Federal law. You may contact the Commissioner of Insurance directly for assistance: Commissioner of Insurance P. O. Box 94214 Baton Rouge, LA 70804-9214 0-000-000-0000 or 0-000-000-0000

External Medical Appeal and Rescission of Coverage. For medical Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with Us and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees with the internal medical Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four one hundred twenty (4120) months days of receipt of the internal medical Appeal decision or Rescission of Coverage. Requests submitted to Us after four one hundred twenty (4120) months days of receipt of the internal medical Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal medical Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of Our receipt of the External Appeal. The IRO will notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and Us for purposes of determining coverage under a health Contract. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary or Investigational, except to the extent that other remedies are available under State or Federal law. You may contact the Commissioner of Insurance directly for assistance: Commissioner of Insurance P. O. Box 94214 Baton Rouge, LA 70804-9214 0-000-000-0000 or 0-000-000-0000

External Medical Appeal and Rescission of Coverage. For medical Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with Us and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees with the internal medical Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four one hundred twenty (4120) months days of receipt of the internal medical Appeal decision or Rescission of Coverage. Requests submitted to Us after four one hundred twenty (4120) months days of receipt of the internal medical Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal medical Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of Our receipt of the External Appeal. The IRO will notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and Us for purposes of determining coverage under a health Contract. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary or Investigational, except to the extent that other remedies are available under State or Federal law. You may contact the Commissioner of Insurance directly for assistance: Commissioner of Insurance P. O. Box 94214 Baton Rouge, LA 70804-9214 0-000-000-0000 or 0-000-000-0000

External Medical Appeal and Rescission of Coverage. For medical Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with Us and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees with the internal medical Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four one hundred twenty (4120) months days of receipt of the internal medical Appeal decision or Rescission of Coverage. Requests submitted to Us after four one hundred twenty (4120) months days of receipt of the internal medical Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal medical Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of Our receipt of the External Appeal. The IRO will notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and Us for purposes of determining coverage under a health Contract. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary or Investigational, except to the extent that other remedies are available under State or Federal law. You may contact the Commissioner of Insurance directly for assistance: D. Expedited Appeals Commissioner of Insurance P. O. Box 94214 Baton Rouge, LA 70804-9214 0-000-000-0000 or 0-000-000-0000 The expedited Appeal process is available for review of the Adverse Benefit Determination involving a situation where the time frame of the standard medical Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the Member may experience pain that cannot be adequately controlled while awaiting a standard Medical Appeal decision. An Expedited Appeal also includes requests concerning an Admission, availability of care, continued stay, or health care service for a Member currently in the emergency room, under observation, or receiving Inpatient care. An Expedited External Appeal is also available if the Adverse Benefit Determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is deemed experimental or Investigational; and the covered person's treating Physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the Adverse Benefit Determination would be significantly less effective if not promptly initiated. Expedited Appeals are not provided for review of services previously rendered. An Expedited Appeal shall be made available to, and may be initiated by the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf. Requests for an Expedited Appeal may be verbal or written. For verbal Expedited Appeals, call 0-000-000-0000 or 0-000-000-0000. For written Expedited Appeals, fax 000-000-0000 or mail to: Blue Cross and Blue Shield of Louisiana Expedited Appeal - Medical Appeals P. O. Box 98022 Baton Rouge, LA 70898-9022