External Review Procedures. Experimental or Investigational In most cases, and except as provided in the next two sections, the Member must follow and exhaust the internal appeals process outlined above before the Member or the Member’s authorized representative may submit a request for external review. In addition, external review as outlined in the next two sections is limited to only those adverse benefit determinations or final internal adverse benefit determinations that certain treatments are experimental or investigational. Standard External Review Procedures There are two types of external review of adverse benefit determinations or final internal adverse benefit determinations that certain treatments are experimental or investigational: a standard external review and an expedited external review. An expedited external review is generally based upon the seriousness of the Member’s medical circumstances and entitles the Member to an expedited notice and decision-making process. The procedures for requesting standard (non-expedited) external reviews are discussed in this section. The procedures for requesting expedited external reviews are discussed in the next section.
External Review Procedures. The Plan shall provide the external review process required, as applicable, by either:
External Review Procedures. 1. After a Member has completed the appeal process, a Member may be entitled to an additional, external review of the Member’s claim at the Corporation’s expense. An external review may be used to reconsider the Member’s claim if the Corporation has denied, either in whole or in part, the Member’s claim. In order to qualify for external review, the claim must have been denied, reduced, or terminated because:
External Review Procedures. In General In most cases, and except as provided in the next two sections, the Member must follow and exhaust the internal appeals process outlined above before the Member may submit a request for external review. In addition, external review is limited to only those adverse benefit determinations that involve:
