Common use of Internal and External Appeals Under Applicable Carrier’s Health Benefits Plan Clause in Contracts

Internal and External Appeals Under Applicable Carrier’s Health Benefits Plan. The following provision shall apply only to applicable Carriers in accordance with the terms, conditions, policies, and procedures of such Carrier’s Health Benefits Plan, as may be required by applicable law, rule, or regulation. 6.4.1 Participating Provider, acting on behalf of the Member with the Member’s consent, may appeal any Adverse Benefit Determination resulting in a denial, termination, or limitation of services or the payment of benefits therefor under the applicable internal appeal processes of Carrier. a. For group and individual Plans, under a stage 1 internal appeal, Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to speak, regarding an Adverse Benefit Determination, with the Carrier’s medical director, or the medical director’s designee who rendered the Adverse Benefit Determination. Stage 1 appeals shall be concluded as required by the exigencies of the situation – within seventy-two (72) hours of receipt of the stage 1 appeal for any Urgently Needed Services, Emergency services, admissions, availability of care, continued stay and health care services for which the Member received Emergency services but has not been discharged from a facility, or within ten (10) calendar days in the case of all other stage 1 appeals. As applicable, at the conclusion of a stage 1 internal appeal, Carrier shall include a written explanation of the right to a further internal or external appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed. b. For group Plans, under a stage 2 internal appeal, Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to pursue his/her/its appeal before a panel of physicians and/or other providers selected by Carrier who have not been involved in Adverse Benefit Determination at issue. Stage 2 appeals shall be concluded as required by the exigencies of the situation – within seventy-two (72) hours of receipt of the stage 2 appeal for any Urgently Needed Services, Emergency services, admissions, availability of care, continued stay and health care services for which the Member received Emergency services but has not been discharged from a facility, or within twenty (20) business days in the case of all other stage 2 appeals. As applicable, at the conclusion of a stage 2 internal appeal, Carrier shall include a written explanation of the right to a further external appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed.

Internal and External Appeals Under Applicable Carrier’s Health Benefits Plan. The following provision shall apply only to applicable Carriers in accordance with the terms, conditions, policies, and procedures of such Carrier’s Health Benefits Plan, as may be required by applicable law, rule, or regulation. 6.4.1 Participating Provider, acting on behalf of the Member with the Member’s consent, may appeal any Adverse Benefit Determination UM determination resulting in a denial, termination, or limitation of services or the payment of benefits therefor under the applicable internal appeal processes of Carrier. a. For group and individual Plans, under Under a stage 1 internal appeal, Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to speak, regarding an Adverse Benefit Determinationadverse service or benefits determination, with the Carrier’s medical director, or the medical director’s designee who rendered the Adverse Benefit Determinationadverse determination. Stage 1 appeals shall be concluded as required by soon as reasonably possible in accordance with the medical exigencies of the situation – within case, but in no event shall exceed: seventy-two (72) hours in the case of receipt of the stage 1 an appeal for any from a determination regarding Urgently Needed Services, Services or Emergency services, admissions, availability of care, continued stay and health care services for (which shall include all situations in which the Member received Emergency services but has not been discharged from a is confined in an inpatient facility), or within ten and five (105) calendar business days in the case of all other stage 1 appeals. As applicable, at At the conclusion of a stage 1 internal appeal, Carrier shall include a written explanation of the right to make a further internal or external stage 2 appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed. b. For group Plans, under Under a stage 2 internal appeal, Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to pursue his/her/its appeal before a panel of physicians and/or other providers selected by Carrier who have not been involved in Adverse Benefit Determination the UM decision at issue. Stage 2 appeals shall be concluded as required by soon as reasonably possible in accordance with the medical exigencies of the situation – within case, but in no event shall exceed: seventy-two (72) hours in the case of receipt appeals of the stage 2 appeal for any determinations regarding Urgently Needed Services, Services or Emergency services, admissions, availability of care, continued stay and health care services for (which shall include all situations in which the Member received Emergency services but has not been discharged from a is confined in an inpatient facility, or within ); and twenty (20) business days in the case of all other appeals. Notwithstanding the foregoing, Carrier may extend the appeal review period for an additional twenty 20 business days upon appropriate notice and under appropriate circumstances. In the event the stage 2 appeals. As applicable, at the conclusion of appeal results in a stage 2 internal appealdenial, Carrier shall include provide the Member and/or Participating Provider, as appropriate, with written notification of the denial and the reasons therefor together with a written explanation notification of his/her/its right to an external appeal. 6.4.2 Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to a further pursue an external appealappeal by filing an application with DOBI at the following address or such other address as DOBI may designate: Office of Managed Care NJ Department of Banking and Insurance X.X. Xxx 000 00 Xxxx Xxxxx Xxxxxx, including the applicable time limits0xx Xxxxx Xxxxxxx, if any, for making the appeal, and to whom the appeal should be addressed.XX 00000-0000