Review Procedure upon Appeal Sample Clauses

Review Procedure upon Appeal. In order to assure Claimants a full and fair review, AvMed’s review procedures will include the following procedures and safeguards: a. Claimants may present evidence and submit written comments, documents, records and other information relating to a Claim. b. upon request and free of charge, Claimants will have reasonable access to and copies of any Relevant Documents. Relevant Document means, any documentation that (i) was relied upon in making a benefit determination; (ii) was submitted, considered or generated in the course of making a benefit determination, without regard to whether it was relied upon in making the determination; (iii) demonstrates compliance with the Plan’s administrative process; and (iv) constitutes a statement of policy or guidance with respect to the Plan concerning the Adverse Benefit Determination for the Claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the Adverse Benefit Determination. c. the review will take into account all comments, documents, records and other information the Claimant submitted relating to the Claim, without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. x. the review will be conducted by an appropriate named fiduciary of XxXxx who is neither the individual who made the initial Adverse Benefit Determination nor the subordinate of such individual. Such person will not defer to the initial Adverse Benefit Determination. e. in deciding an appeal of any Adverse Benefit Determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, medication, or other item is Experimental or Investigational, or not Medically Necessary, the appropriate named fiduciary will consult with a Health Professional who has appropriate training and experience in the field of medicine relevant to the medical judgment. f. the review will provide for the identification of medical or vocational experts whose advice was obtained on behalf of AvMed in connection with a Claimant’s Adverse Benefit Determination, without regard to whether the advice was relied upon in making the Adverse Benefit Determination. g. the review will provide that the Health Professional engaged for purposes of a consultation will be an individual who is neither an individual who was consulted in connection with the initial Adverse Benefit Determination that is the subject of the...