Common use of External Review Clause in Contracts

External Review. SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family Insured of an Insured or the Insured’s treating provider only when the Insured 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. SHL will provide the Insured notice of such an adverse determination which will include the following statement: SHL 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 Insured the information outlined herein 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 Insured resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured or the Insured’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured or the Insured’s Authorized Representative can authorize SHL and the Insured’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 Insured or the Insured’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 Insured or the Insured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702) 486-3587 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxx

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 Insured Member the information outlined herein in Section 11.2 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000000)000-0000 xxx.xxxx.xx.xxxxxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN. Agreement of Coverage

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 Insured Member the information outlined herein in Section 11.2 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 Insured Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxThe determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL The arbiter will be selected by mutual agreement of HPN and the Member. The cost and expense of the arbitration shall be paid by HPN. The decision of the arbiter shall be binding upon the Member and HPN. HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 Insured Member the information outlined herein 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 Insured Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxThe determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family Insured of an Insured or the Insured’s treating provider only when the Insured 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. SHL will provide the Insured notice of such an adverse determination which will include the following statement: SHL 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 Insured the information outlined herein 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 Insured resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured or the Insured’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured or the Insured’s Authorized Representative can authorize SHL and the Insured’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 Insured or the Insured’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 Insured or the Insured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702000) 486000-3587 0000 (000) 000-0000 FaxThe determination of an IRO concerning an External Review in favor of the Insured of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, SHL shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by SHL. Procedures provided under this Plan and if SHL fails to issue a written decision to the Insured within thirty (30) days after the date the appeal was filed, and the Insured or Insured’s Authorized Representative did not request or agree to a delay or, if SHL agrees to permit the Insured to submit the adverse determination to OCHA without requiring the Insured to exhaust all internal SHL appeals procedures. In such event, the Insured shall be considered to have exhausted the internal SHL appeals process. Within five (5) days after OCHA receives a request for External Review, OCHA shall notify the Insured, the Insured’s Authorized Representative and SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Insured relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by SHL’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Insured and the corresponding medical records from the Provider relating to the adverse determination. Within five (0005) 000-0000 xxx.xxxx.xx.xxxdays after the IRO receives the required documentation from SHL, they shall notify the Insured or the Insured’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to SHL within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Insured;  Insured’s Physician;  Insured’s Authorized Representative, if any; and  SHL.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 Insured Member the information outlined herein 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 555 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702002) 486-3587 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxThe determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family Insured member of an Insured or the Insured’s treating provider only when the Insured 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. SHL will provide the Insured notice of such an adverse determination which will include the following statement: SHL 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 AssistanceAssistance (OCHA). Additionally, as per applicable law and regulations, the notice will provide the Insured the information outlined herein 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 Insured resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured or the Insured’s Authorized Representative will also include include: • a HIPAA compliant authorization form by which the Insured or the Insured’s Authorized Representative can authorize SHL and the Insured’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, Review and • and any other forms as required by Nevada law or regulation. The Insured or the Insured’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 Insured or the Insured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below following and should include the signed HIPAA authorization form, authorizing the release of your the Insured’s medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for of the Governor, Consumer Health Assistance 000 Xxxx Xxxxxxxxxx 0000 X. Xxxxxx #0000 Xxx., Xxxxx 000, Xxx Xxxxx Xxxxx, XX 00000 (702) 486Telephone: 000-3587 (000) 000-0000 FaxToll-free: (0-000) -000-0000 xxx.xxxx.xx.xxxWeb: xxxx.xx.xxx/Xxxxxxxx/XXX/ Email: xxx@xxxxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Insured of an adverse determination is final, conclusive and binding. If your plan is governed by Employee Retirement Income and Security Act (ERISA), you may have the right to file a civil action under ERISA if all required mandatory reviews of your claim have been completed. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, SHL shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by SHL.

External Review. SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family Insured of an Insured or the Insured’s treating provider only when the Insured 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. SHL will provide the Insured notice of such an adverse determination which will include the following statement: SHL 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 Insured the information outlined herein 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 Insured resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured or the Insured’s Authorized Representative will also include •  a HIPAA compliant authorization form by which the Insured or the Insured’s Authorized Representative can authorize SHL and the Insured’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 Insured or the Insured’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 Insured or the Insured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702) 486-3587 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxx

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 Insured Member the information outlined herein 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxThe determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person person:  to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination;  or a person authorized by law to provide substituted consent for an Insureda Member;  or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 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 Insured Member the information outlined herein in Section 12.2 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include •  a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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. Agreement of Coverage The Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxWebsite xxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL offers to the Insured or the Insured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insured’s Authorized Representative is a person to whom an Insured has given express written consent to represent the Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insured; or a family Insured of an Insured or the Insured’s treating provider only when the Insured 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. SHL will provide the Insured notice of such an adverse determination which will include the following statement: SHL 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 Insured the information outlined herein 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 Insured resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured or the Insured’s Authorized Representative will also include •  a HIPAA compliant authorization form by which the Insured or the Insured’s Authorized Representative can authorize SHL and the Insured’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 Insured or the Insured’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 Insured or the Insured’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702) 486-3587 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxx.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person person: • to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; • or a person authorized by law to provide substituted consent for an Insureda Member; • or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 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 Insured Member the information outlined herein in Section 12.2 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 Insured Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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. Agreement of Coverage The Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxWebsite xxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person person:  to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination;  or a person authorized by law to provide substituted consent for an Insureda Member;  or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 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 Insured Member the information outlined herein 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include •  a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxWebsite xxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL The arbiter will be selected by mutual agreement of HPN and the Member. The cost and expense of the arbitration shall be paid by HPN. The decision of the arbiter shall be binding upon the Member and HPN. HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 Insured Member the information outlined herein 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxThe determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 AssistanceAssistance (OCHA). Additionally, as per applicable law and regulations, the notice will provide the Insured Member the information outlined herein 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. Evidence of Coverage The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include • include:  a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, • Review and  any other forms as required by Nevada law or regulation. The Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below following and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxWebsite xxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. If your plan is governed by Employee Retirement Income and Security Act (ERISA), you may have the right to file a civil action under ERISA if all required mandatory reviews of your claim have been completed. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for an Insureda Member; or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 AssistanceAssistance (OCHA). Additionally, as per applicable law and regulations, the notice will provide the Insured Member the information outlined herein 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 Insured Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. Evidence of Coverage The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include include: • a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, Review and • and any other forms as required by Nevada law or regulation. The Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below following and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (702000) 486000-3587 0000 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxWebsite xxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. If your plan is governed by Employee Retirement Income and Security Act (ERISA), you may have the right to file a civil action under ERISA if all required mandatory reviews of your claim have been completed. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.

External Review. SHL HPN offers to the Insured Member or the InsuredMember’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, an Insureda Member’s Authorized Representative is a person person:  to whom an Insured a Member has given express written consent to represent the Insured Member in an External Review of an adverse determination;  or a person authorized by law to provide substituted consent for an Insureda Member;  or a family Insured member of an Insured a Member or the InsuredMember’s treating provider only when the Insured 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. SHL HPN will provide the Insured Member notice of such an adverse determination which will include the following statement: SHL 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 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 Insured Member the information outlined herein 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 Insured Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Insured Member or the InsuredMember’s Authorized Representative will also include •  a HIPAA compliant authorization form by which the Insured Member or the InsuredMember’s Authorized Representative can authorize SHL HPN and the InsuredMember’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 Insured Member or the InsuredMember’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 Insured Member or the InsuredMember’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Telephone Number(s) Website Office for Consumer Health Assistance 3320 X. Xxxxxx Xxx., Xxxxx 000 Xxxx Xxxxxxxxxx Xxxxxx #Xxs Vegas NV 89102 Telephone Number(s) (000) 000-0000 Xxx Xxxxx XX 00000 (702) 486-3587 (000) 000-0000 Fax: (000) 000-0000 xxx.xxxx.xx.xxxWebsite xxx.XXX@xxxxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost of conducting an External Review of an adverse determination will be paid by HPN.