Common use of EXTERNAL PEER REVIEW Clause in Contracts

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility may submit a written request for an External Peer Review if Facility is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility can request a review by an external peer review organization to review the medical record in dispute. Facility will normally be notified of the determinations made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility and BCBSM. If BCBSM’s findings are upheld on appeal, Facility will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of Facility’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services or to initiate an action on those issues in an appropriate civil court. Facility’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code J105 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding issues, Facility may submit a written request for a review by the BCBSM Internal Review Committee which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Level Review Conference. Within 60 days of the request, a meeting will be held. Facility, or Facility’s representative upon Xxxxxxxx’s written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Director, Utilization Management Mail Code J423 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility is dissatisfied with the determination of the Internal Review Committee, Facility may appeal the determination to either the Provider Relations Committee (a subcommittee of BCBSM’s Board of Directors) or directly to the Michigan Office of Financial and Insurance Services; or initiate an action in an appropriate civil court.

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility may submit a written request for an External Peer Review if Facility is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility can request a review by an external peer review organization to review the medical record record(s) in dispute. Facility will normally be notified of the determinations determination(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility and BCBSM. If BCBSM’s findings are upheld on appeal, Facility will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of Facility’s 's right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services Regulation (OFIR) or to initiate an action on those issues in an appropriate civil court. Facility’s 's request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code MC J105 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx MC 2005 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding issues, Facility may submit a written request for a review by the BCBSM Internal Review Committee (IRC) which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Level Review Conference. Within 60 days of the request, a meeting will be held. Facility, or Facility’s 's representative upon Xxxxxxxx’s Facility's written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Director, Utilization Management Mail Code MC J423 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility is dissatisfied with the determination of the Internal Review Committee, Facility may appeal the determination to either the Provider Relations Committee (Committee, a subcommittee of BCBSM’s Board board of Directors) directors; or directly to the Michigan Office of Financial and Insurance ServicesOFIR; or initiate an action in an appropriate civil court.

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility Provider may submit a written request for an External Peer Review if Facility is he/she are dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility Provider can request a review by an external peer review organization to review the medical record record(s) in dispute. Facility Provider will normally be notified of the determinations determinations(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility the provider and BCBSM. If BCBSM’s findings are upheld on appeal, Facility Provider will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of FacilityProvider’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services Bureau or to initiate an action on those issues in an appropriate civil a state court. FacilityProvider’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Professional Utilization Review Mail Code J105 MC J103 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx MC 2027 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding Billing & Coding issues, Facility Provider may submit a written request for a review by the BCBSM Internal Review Committee (IRC) which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy policy(ies) in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Managerial-Level Review Conference. Within 60 days of the request, a meeting will be held. FacilityProvider, or Facility’s his/her representative and upon XxxxxxxxProvider’s written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Director, Utilization Management Mail Code MC J423 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility Provider is dissatisfied with the determination of the Internal Review Committee, Facility he/she may appeal the determination to either the Provider Relations Committee (a subcommittee of BCBSM’s Board board of Directorsdirectors) or directly to the Michigan Office of Financial and Insurance ServicesBureau; or initiate an action in an appropriate civil state court.

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility Provider may submit a written request for an External Peer Review if Facility Provider is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility Provider can request a review by an external peer review organization to review the medical record record(s) in dispute. Facility Provider will normally be notified of the determinations determination(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility Provider and BCBSM. If BCBSM’s findings are upheld on appeal, Facility Provider will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of FacilityProvider’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services or to initiate an action on those issues in an appropriate civil a state court. FacilityProvider’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code J105 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. XxxxxxxManager, XX 00000-0000 For Individual Claims disputes, a request for External Peer Professional Utilization Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding issues, Facility may submit a written request for a review by the BCBSM Internal Review Committee which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Level Review Conference. Within 60 days of the request, a meeting will be held. Facility, or Facility’s representative upon Xxxxxxxx’s written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Director, Utilization Management Mail Code J423 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility is dissatisfied with the determination of the Internal Review Committee, Facility may appeal the determination to either the Provider Relations Committee (a subcommittee of BCBSM’s Board of Directors) or directly to the Michigan Office of Financial and Insurance Services; or initiate an action in an appropriate civil court.J103

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility may submit a written request for an External Peer Review if Facility is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility can request a review by an external peer review organization to review the medical record in dispute. Facility will normally be notified of the determinations made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility and BCBSM. If BCBSM’s findings are upheld on appeal, Facility will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of Facility’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services OFIS or to initiate an action on those issues in an appropriate civil court. Facility’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code J105 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding issues, Facility may submit a written request for a review by the BCBSM Internal Review Committee which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Level Review Conference. Within 60 days of the request, a meeting will be held. Facility, or Facility’s representative upon Xxxxxxxx’s written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Director, Utilization Management Mail Code J423 Blue Cross Blue Shield of Michigan J 000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility is dissatisfied with the determination of the Internal Review Committee, Facility may appeal the determination to either the Provider Relations Committee (a subcommittee of BCBSM’s Board of Directors) or directly to the Michigan Office of Financial and Insurance ServicesOFIS; or initiate an action in an appropriate civil court.

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility Provider may submit a written request for an External Peer Review if Facility Provider is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility Provider can request a review by an external peer review organization to review the medical record record(s) in dispute. Facility Provider will normally be notified of the determinations determination(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility Provider and BCBSM. If BCBSM’s findings are upheld on appeal, Facility Provider will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of FacilityProvider’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services Bureau or to initiate an action on those issues in an appropriate civil a state court. FacilityProvider’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code J105 Blue Cross Blue Shield of Michigan Manager, Professional Utilization Review Mail Code J 103 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Blue Cross Blue Shield of Michigan Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 2027 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative Administrative and/or billing and coding Billing & Coding issues, Facility Provider may submit a written request for a review by the BCBSM Internal Review Committee (IRC) which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy policy(ies) in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Managerial-Level Review Conference. Within 60 days of the request, a meeting will be held. FacilityProvider, or FacilityProvider’s representative upon XxxxxxxxProvider’s written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Blue Cross Blue Shield of Michigan Director, Utilization Management Mail Code J423 Blue Cross Blue Shield of Michigan J 423 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility Provider is dissatisfied with the determination of the Internal Review Committee, Facility Provider may appeal the determination to either the Provider Relations Committee (a subcommittee sub-committee of BCBSM’s Board of Directors) or directly to the Michigan Office of Financial and Insurance ServicesBureau; or initiate an action in an appropriate civil state court.

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility may submit a written request for an External Peer Review if Facility is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility can request a review by an external peer review organization to review the medical record record(s) in dispute. Facility will normally be notified of the determinations determination(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility and BCBSM. If BCBSM’s findings are upheld on appeal, Facility will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of Facility’s 's right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services Bureau or to initiate an action on those issues in an appropriate civil court. Facility’s 's request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code MC J105 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx MC 2005 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding issues, Facility may submit a written request for a review by the BCBSM Internal Review Committee (IRC) which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Level Review Conference. Within 60 days of the request, a meeting will be held. Facility, or Facility’s 's representative upon Xxxxxxxx’s 's written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Director, Utilization Management Mail Code MC J423 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility is dissatisfied with the determination of the Internal Review Committee, Facility may appeal the determination to either the Provider Relations Committee (Committee, a subcommittee of BCBSM’s Board board of Directors) directors; or directly to the Michigan Office of Financial and Insurance ServicesBureau; or initiate an action in an appropriate civil court.

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility Provider may submit a written request for an External Peer Review if Facility Provider is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility Provider can request a review by an external peer review organization to review the medical record record(s) in dispute. Facility Provider will normally be notified of the determinations determination(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility Provider and BCBSM. If BCBSM’s findings are upheld on appeal, Facility Provider will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of FacilityProvider’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services (OFIS) or to initiate an action on those issues in an appropriate civil a state court. FacilityProvider’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code J105 Blue Cross Blue Shield of Michigan Manager, Professional Utilization Review Mail Code J 106 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Blue Cross Blue Shield of Michigan Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 2027 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative Administrative and/or billing and coding Billing & Coding issues, Facility Provider may submit a written request for a review by the BCBSM Internal Review Committee (IRC) which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy policy(ies) in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Managerial-Level Review Conference. Within 60 days of the request, a meeting will be held. FacilityProvider, or FacilityProvider’s representative upon XxxxxxxxProvider’s written request, may be present at this hearing. BCBSM will communicate the determination of the Committee within 30 days of the meeting date. The request for an IRC hearing should be mailed to: Blue Cross Blue Shield of Michigan Director, Utilization Management Mail Code J423 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 If Facility Provider is dissatisfied with the determination of the Internal Review Committee, Facility Provider may appeal the determination to either the Provider Relations Committee (a subcommittee of BCBSM’s Board board of Directorsdirectors) or directly to the Michigan Office of Financial and Insurance ServicesServices (OFIS); or initiate an action in an appropriate civil state court.