External Review Process. A Member shall have four (4) months from the receipt of notice of the Plan’s decision to appeal the denial resulting from the Internal Appeal Process by requesting external review of the decision. To be eligible for external review, the decision of the Plan to be reviewed must involve: i) a Claim that was denied involving medical judgment, including application of the Plan’s requirements as to medical necessity, appropriateness, health care setting, level of care, effectiveness of a Covered Service or a determination that the treatment is experimental or investigational; or ii) a determination made by the Plan to rescind a Member’s coverage or to deny the enrollment request of an individual due to ineligibility for coverage under this Agreement. In the case of a denied Claim, the request for external review may be filed by either the Member or a health care Provider, with the written consent of the Member in the format required by or acceptable to the Plan. The request for external review should include any reasons, material justification and all reasonably necessary supporting information as part of the external review filing.
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Samples: Individual Comprehensive Major Medical Preferred Provider Qualified High Deductible Health Plan Subscription Agreement, Individual Comprehensive Major Medical Preferred Provider Subscription Agreement, Individual Comprehensive Major Medical Preferred Provider Qualified High Deductible Health Plan Subscription Agreement
