Medical Pre–notification Helpline Sample Clauses

Medical Pre–notification Helpline. For those services determined by Employer and provided in writing to Claim Administrator that require pre–notification, advance Claim Administrator review of medical necessity, based on Claim Administrator’s standard medical and utilization management criteria and policies, of such services covered under the Plan; access to toll–free medical pre–notification helpline for Covered Persons and their health care Providers to call for assistance. • INTERNAL APPEALS Determination of properly filed internal appeal requests received by Claim Administrator from a Covered Person or a Covered Person’s authorized representative. • EXTERNAL REVIEW COORDINATION Claim Administrator will coordinate external reviews of certain adverse benefit determinations for Employer as described and for the fee set forth in the most current ASO BPA to this Agreement. Claim Administrator’s coordination includes reviewing external review requests to assess whether they meet the eligibility requirements, referring requests to IROs, and reversing the Plan’s determinations if so indicated by the IRO. External reviews shall be performed by an IRO and not Claim Administrator. Amounts received by Claim Administrator and IROs may be revised from time to time and may be paid each time an external review is undertaken. • VIRTUAL VISIT PROGRAM MANAGEMENT Provide or arrange for a program that allows Covered Persons to access benefits for certain Covered Services remotely from virtual visit participating Providers via i) interactive audio communication (via telephone or similar technology) and/or ii) interactive audio/video examination and communication (via online portal, mobile app or similar technology), where available.