Common use of Internal Appeal Procedure Clause in Contracts

Internal Appeal Procedure. If You are not satisfied with Our decision regarding Your Grievance, You have the right to submit an Appeal to Us within 180 days of Our decision regarding Your Grievance. You may file an appeal in writing or You may call MDwise Customer Service directly and a Customer Service Representative will assist You in filing the Appeal. We will acknowledge Your Appeal, orally or in writing, within three business days of Our receipt of it. (A) Have knowledge of the Health Services at issue. (B) Are in the same licensed profession as the Provider who proposed, refused or delivered the Health Service at issue. (C) Are not involved in the matter giving rise to the appeal or the previous Grievance process. (D) Do not have a direct business relationship with You or with the Provider who recommended the Health Service at issue. You or Your Designated Representative may (A) appear in person before the Committee, or (B) communicate with the Committee through appropriate other means, if unable to attend in person. You will have access free of charge, upon request, to copies of all relevant documents, records, and other information, as described by applicable U. S. Department of Labor regulations. To support Your Appeal, You should submit to the Committee any written issues, arguments, comments, or other documented evidence. The Committee shall review all findings and pertinent documents, including any aspects of clinical care, whether or not We have considered them previously. The Committee will not afford any special deference to the original denial of Your Grievance. In no event shall Your claim that was previously denied under the terms of the Contract and upheld by an Appeals ruling be reconsidered by the Committee for review. The Committee’s decision regarding Your Appeal will be made as soon as possible and with regard to the clinical urgency of the Appeal, but not later than (A) 30 days after the Appeal was filed, for Pre-Service Grievances. (B) 45 days after the Appeal was filed, for Post-Service Grievances. The Committee's decision regarding Your Appeal of an adverse benefit determination for an Urgent Grievance will be made not later than 72 hours after the receipt of Your request for review.