External Review. In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact XxXxx’s Member Engagement Center.
External Review. Contractor shall comply with State and Federal laws, rules and regulations relating to the external review process, including independent medical review, available to Enrollees for Covered Services.
External Review. The MA Organization will comply with any requests by Quality Improvement Organizations to review the MA Organization's medical records in connection with appeals of discharges from hospitals, skilled nursing facilities, and home health agencies.
External Review. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the Member is unable to provide consent. Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN will provide the Member notice of such an adverse determination which will include the following statement: HPN has denied your request for the provision or payment of a requested healthcare service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for External Review to the Office for Consumer Health Assistance. Additionally, as per applicable law and regulations, the notice will provide the Member the information outlined in Section 10.2 as well as the following: The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state in which the Member resides. The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, and any other forms as required by Nevada law or regulation. The Member or the Member’s Authorized Representative may submit a request directly to OCHA for an External Review of an adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member or the Member’s Authorized Representative receivin...
External Review. If you are not satisfied with a final internal appeal determination based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, you may have the right to have our decision reviewed by an Independent Review Organization (“IRO”). An IRO is an independent organization of medical reviewers who are certified by the State of Washington Department of Health to review medical and other relevant information. There is no cost to you for an external review. We will send you an External Review Request form, notifying you of your rights to an external review, within 3 business days of the end of the Level II appeal process. We must receive your written request for an external review within 180 days of the date of our final internal adverse benefit determination. Your request must include a signed waiver granting the IRO access to medical records and other materials that are relevant to your request. We will notify the IRO of your request for an external review. We will provide you with the name and contact information of the IRO within 1 day of giving the IRO notice of your request for review. The IRO will accept additional information in writing from you for up to 5 business days from the date we notify them of your request for external review. The IRO is required to consider any information you provide within this period when it conducts its review. The IRO will let you, your authorized representative, if any, or your attending physician know where to submit any additional information and when the information must be provided. We will forward your medical records and other relevant materials for your external review directly to the IRO. We will also provide the IRO with any additional information they request that is reasonably available to us. Once the external review is completed, the IRO will notify you and us in writing of their decision. If you have requested an expedited external review, the IRO will notify you and us of their decision immediately by phone, e-mail or fax after they make their decision, and will follow up with a written decision by mail. CHPW is bound by the decision made by the IRO. If the IRO overturns our final internal adverse benefit determination, we will implement their decision promptly. If the IRO upholds the final internal adverse benefit determination, there is no further review available under this plan's internal appeals or external review process. You may, however, have ot...
External Review. A process, independent of all affected parties, to determine if a health care service is Medically Necessary and Medically Appropriate, experimental/investigational. Independent review typically (but not always) occurs after all appeal mechanisms available within the health benefits plan have been exhausted. Independent review can be voluntary or mandated by law. Independent Review Organization: An independent review organization (IRO) acts as a third-party medical review resource which provides objective, unbiased medical determinations that support effective
External Review. The M+C Organization will have an agreement with an independent quality review and improvement organization (review organization) approved by CMS. [422.154(a)]
(a) The agreement will be consistent with CMS guidelines and will:
(i) Require that the M+C Organization allocate adequate space for use of the review organization whenever it is conducting review activities and provide all pertinent data, including patient care data, at the time the review organization needs the data to carry out the reviews and make its determinations, and
(ii) Except in the case of complaints about quality, exclude review activities that CMS determines would duplicate review activities conducted as part of an accreditation process or as part of CMS monitoring. [422.154(b)]
External Review. Once the internal appeal process is exhausted (except as otherwise noted in this procedure) the Member may file a request for an external review with the Director of the Department of Health for the District of Columbia at the following address: Grievance Coordinator Department of Health Office of the General Counsel 000 Xxxxx Xxxxxxx Xxxxxx, X.X. Room 4119 Washington, DC 20002 (000) 000-0000 A request for an external review must be received by the Department of Health within thirty (30) working days after the date of receipt of the appeal hearing decision. Instructions on how to request an external review are included with the Appeal Hearing Panel’s response to the second level appeal.
External Review. If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of our determination within 72 hours. If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours. You are responsible for paying the Annual Deductible stated in the Schedule of Benefits which is attached to your Policy before Benefits for Prescription Drug Products under this Policy are available to you unless otherwise allowed under your Policy. We may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible.
External Review. Provider acknowledges that Payer is required under the Medicare Advantage Program to have an agreement with an independent quality review and improvement organization approved by CMS to perform an external review of the quality management and improvement program. Provider agrees to comply with the activities of Payer’s independent quality review and improvement organization in accordance with the applicable Medicare Advantage Program requirements, including, without limitation, (i) allocating adequate space at Provider’s facilities for use of the review organization whenever it is conducting review activities; and (ii) providing all pertinent data, including without limitation, patient care data, at the time the review organization needs the data to carry out the review and make its determination.
