INDEPENDENT EXTERNAL REVIEW. You or your authorized representative may make a request for a standard external review or expedited external review of an Adverse Determination or Final Adverse Determination by an independent review organization (IRO).
INDEPENDENT EXTERNAL REVIEW. Appeal decisions involving an Adverse Utilization Determination or an Adverse Health Care Treatment Decision by Health Options are eligible for review by an independent review organization designated by the Maine Bureau of Insurance. Adverse Utilization Determinations for purposes of independent external review include Medical Necessity, appropriateness, health care setting, level of care, effectiveness of a covered Benefit, Experimental or Investigational treatment or services, and rescission. The external review decision must be made within 30 days after the independent review organization receives the request for the review. However, the decision must be made within 72 hours if delay would seriously jeopardize the life or health of the Member or would jeopardize the Member’s ability to regain maximum function. If the independent review organization decides in your favor, the decision is binding on Health Options. Normally, you must first complete Health Options’ first and second level Appeals process to be eligible for independent external review. However, you are not required to complete the first and second level Appeals process if:
a. Health Options has failed to make a decision on your first or second level Appeal in the time frames noted above;
INDEPENDENT EXTERNAL REVIEW. Enrollees may request an independent external review within one hundred twenty (120) Calendar Days of notification that an appealed Adverse Benefit Determination has been upheld or when the Appeal process has been deemed exhausted by way of Insurer’s failure to adhere to the notification and timing requirements of 42 CFR 457.1260 which incorporates 42 CFR 438.408. Insurer shall maintain a contract with an Independent Review Organization (IRO) for the provision of Enrollees’ option to have a post-appeal independent review. Such contract shall specify and meet all state and federal laws, regulations and guidance applicable to CHIP Grievance and Appeal process requirements and subcontractor requirements, including FHKC’s audit rights. Insurer shall provide a quarterly report listing all independent reviews the IRO handled in the quarter, including the date the independent review was requested, the date the IRO made a final decision, the outcome of the review, whether Insurer has since received any Grievances related to the independent review and any other information requested by FHKC. Enrollees and the Enrollee’s representative or the legal representative of a deceased Xxxxxxxx’s estate shall be included as parties to the review. In the event the independent external review overturns an Adverse Benefit Determination, Insurer shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires, but no later than seventy-two (72) hours from the independent external review determination date. Insurer is responsible for the full cost of all independent reviews.
INDEPENDENT EXTERNAL REVIEW. A. You have the right to an “independent external review” of an appealable decision made by MVP. An independent external review is an independent review of our decision by a third party known as an independent review organization. Independent review organizations (“IRO”) are selected by the DFR and must not have any conflict of interest associated with the review. You have the right to request a review by a State approved IRO after the first level of internal appeal has been exhausted or after the voluntary second level of appeal where MVP has denied coverage based on medical necessity; experimental or investigational nature of the services; off-label use of a drug; choice of provider; and for mental health and substance abuse reviews. You do not have the right to external review of any other decisions, even if those other decisions affect your eligibility or benefits. Exhaustion of the internal grievance process is not required when MVP has waived the internal grievance process or has been deemed to have waived the internal grievance process by failing to adhere to grievance process time requirements. (An expedited External Appeal can be made simultaneously with an expedited first level of internal appeal.) The right to independent external review is contingent on the Enrollee’s exhaustion of MVP’s first level internal grievance process unless as noted above. You may have the right to an expedited external review if the subject of the review concerns an emergency medical condition, emergency services, or urgently needed care. The timeframes for expedited external reviews are shorter than the timeframes for standard external reviews. You may request an expedited external appeal even if your internal appeal was non-expedited.
B. You must request this review within 120 days or 4 months, whichever is longer, from the date any of the following occur:
(i) You receive written documentation of MVP’s final grievance decision and notice of appeal rights; or
(ii) MVP waives the required grievance process; or
(iii) MVP is deemed to have waived the grievance process by failing to adhere to grievance process time requirements. To request an independent, external review, you must call the DFR at 800-964- 1784.
C. You may request an independent external review only if the service that is the subject of the review is a Covered Service.
