Common use of External Review Clause in Contracts

External Review. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: Additionally, as per applicable law and regulations, the notice will provide the 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 Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: 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 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 Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 555 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s(002) 486-3587 (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person person:  to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination;  or a person authorized by law to provide substituted consent for a Member;  or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: Additionally, as per applicable law and regulations, the notice will provide the 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 Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include  a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: 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 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 Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: 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 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 Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000000)000-0000 Website 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: 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 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 Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. 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 Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Member; or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: 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 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 Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. HPN SHL offers to the Member Insured or the MemberInsured’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Memberan Insured’s Authorized Representative is a person to whom a Member an Insured has given express written consent to represent the Member Insured in an External Review of an adverse determination; or a person authorized by law to provide substituted consent for a Memberan Insured; or a family member Insured of a Member an Insured or the MemberInsured’s treating provider only when the Member 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. HPN SHL will provide the Member 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 Member 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 Member Insured resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member Insured or the MemberInsured’s Authorized Representative will also include: • include a HIPAA compliant authorization form by which the Member Insured or the MemberInsured’s Authorized Representative can authorize HPN SHL and the MemberInsured’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 Member Insured or the MemberInsured’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 Member Insured or the MemberInsured’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website xxx.xxxx.xx.xxx The determination of an IRO concerning an External Review in favor of the Member 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, HPN 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 HPNSHL. 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 (5) days 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person person:  to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination;  or a person authorized by law to provide substituted consent for a Member;  or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: Additionally, as per applicable law and regulations, the notice will provide the 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 Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include  a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 (000) 000-0000 Fax: (000) 000-0000 Website 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. HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination. For the purposes of this section, a Member’s Authorized Representative is a person person:  to whom a Member has given express written consent to represent the Member in an External Review of an adverse determination;  or a person authorized by law to provide substituted consent for a Member;  or a family member of a Member or the Member’s treating provider only when the 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. HPN will provide the Member notice of such an adverse determination which will include the following statement: Additionally, as per applicable law and regulations, the notice will provide the 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 Member resides. •  The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include: • include  a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’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 Member or the Member’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 Member or the Member’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 following 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 Office for Consumer Health Assistance 3320 X. Xxxxxx Xxx., Xxxxx 000 Xxxx Xxxxxxxxxx Xxxxxx #0000 Xxx Xxxxx XX 00000 Telephone Number(s) (000) 000-0000 Xxs Vegas NV 89102 (000) 000-0000 Fax: (000) 000-0000 Website 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.