Common use of Level II Appeal Process (Voluntary) Clause in Contracts

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Health Options review panel. Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Health Options will have a lawyer presenting Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 0-000-000-0000 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Health Options review panel. Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers Clinical Peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers Clinical Peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. SAMPLE You may submit supporting materials both before and at the review meeting and you may ask questions of Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Health Options will have a lawyer presenting Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 0-0- 000-000-0000 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Community Health Options review panel. Community Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers Clinical Peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers Clinical Peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Community Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Community Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Community Health Options will have a lawyer presenting Community Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 1‐800‐300‐5000 (within Maine) or 0-000-000-0000 1‐207‐ 624‐8475 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Health Options review panel. Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers Clinical Peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers Clinical Peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Health Options will have a lawyer presenting Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. SAMPLE If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 0-000-000-0000 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx34 State House Station, XxxxxxxAugusta, XX 00000ME 04333; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Community Health Options review panel. Community Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers Clinical Peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers Clinical Peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Community Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Community Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Community Health Options will have a lawyer presenting Community Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision;; SAMPLE b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 01-000207- 624-000-0000 8475 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Community Health Options review panel. Community Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers Clinical Peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers Clinical Peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Community Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Community Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Community Health Options will have a lawyer presenting Community Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. SAMPLE If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 01-000207- 624-000-0000 8475 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). SAMPLE If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Health Options review panel. Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Health Options will have a lawyer presenting Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 0-000-000-0000 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Health Options review panel. Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Health Options will have a lawyer presenting Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. SAMPLE If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 (within Maine) or 01-000207- 624-000-0000 8475 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.

Level II Appeal Process (Voluntary). If you disagree with the decision of the Level I Appeal process, you may request a second level Appeal. Your Level II Appeal will be reviewed by a Community Health Options review panel. Community Health Options shall appoint a panel for each Level II Appeal, which shall include one or more reviewers not involved in the previous adverse determinations. If your Level II Appeal involves a medical determination, the panel will include one or more clinical peers not involved in previous adverse determinations. A second level Appeal decision involving a medical determination adverse to the Member must have the concurrence of a majority of the clinical peers on the panel. You must make a Level II Appeal within 180 days after the date of the Level I Appeal decision. If you do not submit a Level II Appeal within this time, you will lose your right to a Level II Appeal unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You may waive your right to the Level II Appeal process and request an independent external review as provided below. You have a right to attend the meeting to present your case to the review panel. You or your Designee must tell your Appeals Coordinator if you wish to attend. You may also participate in the meeting by telephone or video conferencing if you wish – please let your Appeals Coordinator know. You may submit supporting materials both before and at the review meeting and you may ask questions of Community Health Options representatives. You also may bring someone with you or be represented by someone, including a lawyer, at the review meeting. You also have the right to obtain free of charge from Community Health Options your medical case and information relevant to your Appeal that is not confidential or privileged. If you request to participate in the review panel, we will hold a review meeting within 45 days after we receive your request for a Level II Appeal. You will be notified in writing at least 15 days in advance of the review meeting. We will let you know if Community Health Options will have a lawyer presenting Community Health Options’ case. If you need to postpone the review meeting, please let your Appeals Coordinator know. The decision of the review panel will be sent to you in writing within five business days after a review meeting. If you do not request to participate in the review panel, you will be provided with a written response to your Level II Appeal within 30 calendar days after we receive your request for a Level II Appeal. If we deny your Level II Appeal, we will give you a written decision, which will include: a. The reason(s) for the decision, including reference to the specific Agreement provision, rule, protocol, guideline, evidence or other documents that we used to make the decision; b. A statement that you may receive, at no cost to you upon request, reasonable access to, and copies of, all documents, records, provisions, rules, protocols, guidelines, internal rules and/or other criteria used in the Appeal decision or initial denial decision; c. If the denial was based on Medical Necessity or Experimental treatment or similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the denial or you will be told that you may request such explanation at no cost; d. The title and qualifications of the person(s) who conducted the review; e. Notice of your right to contact the Maine Bureau of Insurance by telephone at 0-000-000-0000 1‐800‐300‐5000 (within Maine) or 0-000-000-0000 1‐207‐ 624‐8475 (outside Maine) or by mail at 00 Xxxxx Xxxxx Xxxxxxx, Xxxxxxx, XX 00000; and f. A statement describing all other dispute resolution options available to you, including external review.