Common use of Final Adverse Benefit Determination Clause in Contracts

Final Adverse Benefit Determination. An Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination. Post-Service Claim An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or Your unborn child’s; or • In the opinion of the treating physician, would subject You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or Your Authorized Representative, or a treating Provider or facility may submit an appeal. If You need assistance in preparing the appeal, or in submitting an initial appeal (Level I) verbally, You may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Alliant Health Plans Administrative PO BOX 1247 Claims Appeals: Dalton, GA 30722 Med Pharm Magellan Rx Management Appeals: Appeals Department PO BOX 1459 Maryland Heights, MO 63043 Pharmacy Magellan Rx Management Appeals: Appeals Department PO BOX 1599 Maryland Heights, MO 63043 If You are Hearing impaired, You may also contact Alliant via the National Relay Service at 711. You (or Your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from the date Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact You (or Your Authorized Representative) in writing or by telephone to inform You of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS or 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 CALENDAR DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 CALENDAR DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have Our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after You have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after You receive notice of the denial of the claim or appeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx . To request an external review by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx000 Xxxxxxxxx, XX00000 Fax: (000)000-0000 If You have any questions or concerns during the external appeal process, You (or Your Authorized Representative) can call the toll-free number (000) 000-0000 or visit www. xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, You may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

Final Adverse Benefit Determination. An Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination. Post-Service Claim An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or Your unborn child’s; or • In the opinion of the treating physician, would subject You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or Your Authorized Representative, or a treating Provider or facility may submit an appeal. If You need assistance in preparing the appeal, or in submitting an initial appeal (Level I) verbally, You may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Alliant Health Plans Administrative PO BOX 1247 Claims Appeals: Dalton, GA 30722 Med Pharm Magellan Rx Management Appeals: Appeals Department PO BOX 1459 Maryland Heights, MO 63043 Pharmacy Magellan Rx Management Appeals: Appeals Department PO BOX 1599 Maryland Heights, MO 63043 If You are Hearing impaired, You may also contact Alliant via the National Relay Service at 711. You (or Your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from the date Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact You (or Your Authorized Representative) in writing or by telephone to inform You of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS or 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 CALENDAR DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 CALENDAR DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have Our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after You have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after You receive notice of the denial of the claim or appeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx . To request an external review by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx000 Xxxxxxxxx, XX00000 Fax: (000)000000) 000-0000 If You have any questions or concerns during the external appeal process, You (or Your Authorized Representative) can call the toll-free number (000) 000-0000 or visit www. xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, You may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

Final Adverse Benefit Determination. An Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination. Post-Service Claim Claim‌ An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim Claim‌ An Adverse Benefit Determination was rendered, rendered and the requested service has not been provided. Urgent Care Services Claim Claim‌ An Adverse Benefit Determination was rendered, rendered and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or Your your unborn child’s; or • In the opinion of the treating physician, would subject You you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL APPEAL‌ You, or Your your Authorized Representative, or a treating Provider or facility may submit an appeal. If You you need assistance in preparing the appeal, or in submitting an initial appeal (Level I) verbally, You you may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Claims Appeals: Alliant Health Plans Administrative PO BOX 1247 Claims Appeals: DaltonXX XXX 0000 Xxxxxx, GA 30722 Med Pharm XX 00000 Medical Appeals (Level I & II): Alliant Health Plans c/o Magellan Health Appeals Department XX Xxx 0000 Xxxx Xxxx Xxxx, XX 00000 Pharmacy Appeals (Level I & II): Magellan Rx Management Appeals: Appeals Department PO BOX 1459 Maryland Heights0000 Xxxxxxxxxx Xxx Xxxxx. Xxxx, MO 63043 Pharmacy Magellan Rx Management Appeals: Appeals Department PO BOX 1599 Maryland Heights, MO 63043 XX 00000 If You you are Hearing impaired, You impaired you may also contact Alliant via the National Relay Service at 711. You (or Your your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from the date Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact You you (or Your your Authorized Representative) in writing or by telephone to inform You you of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND RESPONDING TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS or 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 CALENDAR DAYS POST-SERVICE AUTHORIZATION APPEALS (LEVEL I & II) WITHIN 30 CALENDAR DAYS POST-SERVICE AUTHORIZATION (LEVEL I & II) WITHIN 30 DAYS EXHAUSTION OF PROCESS PROCESS‌ The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL APPEAL‌ You may have the right to have Our our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, considered or a health care coverage rescission reviewed externally after You you have exhausted the internal appeals rights provided by AlliantAHP. You must file a request for an external review within 123 days after You you receive notice of the denial of the claim or appeal. How do I request external review? review?‌ You can submit a request for an external review online at xxx.xxxxxxxxxxxxxx.xxx, appeal by calling (000) 000-0000 to ask for request an external review request form, or . The form can be faxed to (000) 000-0000. You may also send an external appeal in writing by sending the request via an email to xxxx@xxxxxxx.xxx . To request an external review or by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx000 Xxxxx 000 Xxxxxxxxx, XX00000 Fax: (000)000-0000 XX 00000 If You you have any questions or concerns during the external appeal process, You you (or Your your Authorized Representative) can call the toll-free number (000) 000-0000 or visit www. xxxxxxxxxxxxxx.xxxxxx.xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? review?‌ In some cases, You you may ask for an expedited (faster than usual) external review. An expedited review may be requested when: