Common use of External Review Process Clause in Contracts

External Review Process. An external review organization is an independent entity under contract with the State of Minnesota to review health plan appeals. If you or someone acting on your behalf has exhausted, or are deemed under applicable law to have exhausted, PIC’s internal appeals processes as described in the “Internal Appeals Process” section of this contract, you or your authorized representative may file a request for external review, along with your filing fee of $25, as noted below, with the Minnesota Department of Commerce at the address below: External Review Process Minnesota Department of Commerce 00 Xxxx Xxxxxxx Xxxxx Suite 280 St. Xxxx, MN 55101-2198 You are deemed to have exhausted PIC’s internal appeals process, if PIC waives the exhaustion requirement, PIC fails to substantially comply with the requirements of this section or you request an expedited external review at the same time you qualify for and request an acute care service appeal. If you want an external review, you must request it within six months after the date of PIC’s denial determination. Cases involving fraudulent marketing and agent misrepresentation are not eligible for external review. External review decisions are binding on PIC, but are not binding on you. The fee for an external review is $25 and the maximum fee you may be charged in one year for external reviews is $75. This fee may be waived due to hardship and will be refunded by the Minnesota Department of Commerce, its contracted external review organization, or its designee if you prevail and PIC’s denial decision is completely reversed. You or someone acting on your behalf may file a complaint with the Commissioner of Commerce at any time. You may reach the Minnesota Department of Commerce at 651.539.1600 within the Twin Cities metropolitan area or by calling 0.000.000.0000 from outside the Twin Cities.