Common use of INDEPENDENT EXTERNAL REVIEW Clause in Contracts

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. Appeal decisions involving an Adverse Utilization Determination Determination, or an Adverse Health Care Treatment Decision by Community 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 Community Health Options. Normally, you must first complete Community 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. Community Health Options has failed to make a decision on your first or second level Appeal in the time frames noted above;

INDEPENDENT EXTERNAL REVIEW. Appeal decisions involving an Adverse Utilization Determination or an Adverse Health Care Treatment Decision by Community 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 Community Health Options. Normally, you must first complete Community 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. Community Health Options has failed to make a decision on your first or second level Appeal in the time frames noted above;

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. SAMPLE 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;