Independent Medical Review Sample Clauses

Independent Medical Review. External independent review is available to members for review of denials of experimental therapies where such therapies might be indicated for treatment of a life threatening condition or seriously debilitating illness or for denials based on service not being medically necessary by contacting Member Services within five business days of the denial. The request for an independent medical review will be reviewed by the Dental Director or, if necessary, referred to the Quality Assurance Committee.

Independent Medical Review. In accordance with 42 CFR 438.204(d), the Agency shall provide for an independent review of all Medicaid services provided or arranged by the contractor. The contractor shall provide information necessary for the review based upon the requirements of the Agency or the Agency's independent peer review contractor. The information shall include quality outcomes concerning timeliness of, and access to, services covered under the contract. The review shall be performed at least annually by an entity outside state government. If the medical audit indicates that quality of care is unacceptable pursuant to contractual requirements, the Agency and the department may restrict the contractor's enrollment activities pending attainment of acceptable quality of care.

Independent Medical Review. The Township reserves the right to require the employee to have an independent medical examination by a physician selected by and paid for by the Township at any time when the employee is receiving injured on duty leave, and reserves the right to review the employee’s status every thirty (30) days.

Independent Medical Review. 1. The Member may request review by a certified independent review organization of an Adverse Determination if: a. the Member has completed the grievance and appeals hearing process and the Adverse Determination has been upheld, or b. the HMO has exceeded the timelines for grievances and appeal hearings set forth above without good cause and without reaching a decision. 2. Not later than the third business day after the date the HMO receives a request for an independent medical review, HMO will provide to the Independent Medical Review Organization designated by the Office of the Insurance Commissioner: a. the medical records of the Member that are relevant to the review; b. documents used by HMO in making the determination to be reviewed; c. a list of each Physician or Health Care Professional who has provided care to the d. the treating Provider’s recommendations; and e. the terms and conditions of coverage of the Member’s plan. 3. HMO will make available to the Member and/or the Member’s treating Provider copies of all materials provided to the independent review organization. The Member and the Member’s treating Provider will make available to HMO any information that they provided to the independent review organization in support of their appeal. 4. If the independent medical review request involves services which the Member is currently receiving (for example, the Member is currently hospitalized and HMO has determined that coverage for continued inpatient care is not Medically Necessary) HMO will continue to provide coverage for the services until the independent review organization makes their decision. If the independent review organization decision upholds the HMO’s determination, the Member will be responsible for the cost of the continued health care services. 5. If the independent review organization’s determination overturns the HMO’s decision the HMO will promptly comply with the final determination. 6. The Member is not responsible for any portion of the independent review organization’s charges.

Independent Medical Review. Members have the right to an independent review of decisions by the HMO to deny, modify or delay coverage for health care service(s) based on Medical Necessity (Disputed Health Care Services). Members have the right to an independent medical review of decisions by the HMO to deny coverage for health care services which have been determined by the HMO to be excluded as Experimental and Investigative. Additional information about treatments which will not be excluded as Experimental and Investigative can be found under Transplant Benefits and Additional Benefits – Clinical Cancer Trials, in the Covered Benefits section of the EOC. Section A below describes how Members may request Independent Medical Review for certain Experimental and Investigative treatments related to Life-Threatening or Seriously Debilitating Illnesses. The Department of Managed Health Care will manage the independent medical review process, which is available to Members when they meet the criteria developed by the Department of Managed Health Care. Members are not required to pay any application or processing fees to request or receive independent medical review. Independent medical review is available in addition to HMO Complaint and Appeal procedures and any other remedies available to the Member by law. Members should be aware that the decision not to participate in the independent medical review process may cause the Member to forfeit any statutory right to pursue legal action against the HMO regarding a Disputed Health Care Service.

Independent Medical Review. The state regulatory processes available to the Participant in addition to USBHPC’s grievance process to resolve a disputed health care service, as set forth in Article 3 of this Combined Evidence of Coverage and Disclosure Form.