External Review by Independent Review Organization. In accordance with IC 27-13-10.1-1 and IC 27-8-29-12, the Contractor must maintain an external grievance procedure for the resolution of decisions related to an adverse utilization review determination, an adverse determination of medical necessity or a determination that a proposed service is experimental or investigational. An external review does not inhibit or replace the member’s right to appeal the Contractor’s decision to a State fair hearing. A member or a member’s representative may file a written request for a review of the Contractor’s decision by an independent review organization (IRO) within one hundred and twenty (120) calendar days of receipt of the appeal decision. The IRO shall render a decision within fifteen (15) business to uphold or reverse the Contractor’s decision. The determination made by the IRO is binding on the Contractor.
Appears in 7 contracts
Samples: Contract #0000000000000000000018225, Contract #0000000000000000000018227, Contract #0000000000000000000018227
External Review by Independent Review Organization. In accordance with IC 27-13-10.1-1 and IC 27-8-29-121, the Contractor must shall maintain an external grievance procedure for the resolution of decisions related to an adverse utilization review determination, an adverse determination of medical necessity necessity, or a determination that a proposed service is experimental or investigational. An external review does not inhibit or replace the member’s right to appeal the Contractor’s a Contractor decision to a State fair hearing. A member may seek external review by an IRO, and such process may run concurrently with a State fair hearing. Within thirty-three (33) calendar days from the date of the Contractor’s decision, a member, or a member’s representative may file a written request for a review of the Contractor’s decision by an independent review organization (IRO) within one hundred and twenty (120) calendar days of receipt of the appeal decision). The IRO shall render a decision within fifteen (15) business to uphold or reverse the Contractor’s decisiondecision within seventy-two (72) hours for an expedited appeal, or fifteen (15) business days for a standard appeal. The determination made by the IRO independent review organization is binding on the Contractor.
Appears in 1 contract
Samples: Professional Services Contract Contract #0000000000000000000018314