Common use of Request for Expedited External Review Clause in Contracts

Request for Expedited External Review. Under the following circumstances, the Member may request an expedited external review: a. If the Member received an adverse benefit determination that denied the Member’s claim and: 1. the Member filed a request for an internal Urgent Care appeal; and 2. the delay in completing the internal appeal process would seriously jeopardize the life or health of the Member or the Member’s ability to regain maximum function; or b. Upon receipt of a final internal adverse benefit determination which involves: 1. a medical condition of the Member for which a delay in completing the standard external review would seriously jeopardize the Member’s life or health or the Member’s ability to regain maximum function; or 2. an admission, availability of care, a continued stay, or a health care item or service for which the Member received Emergency Services, but has not been discharged from a facility.