Common use of Standard External Review Clause in Contracts

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after  the Member Insured has exhausted the internal HPN SHL Appeals Procedures provided under this Plan and or  if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or,  if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN SHL appeals procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN SHL appeals process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member Insured relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPNSHL’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member Insured and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPNSHL, they shall notify the Member Insured or the MemberInsured’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN SHL within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  MemberInsured;  MemberInsured’s Physician;  MemberInsured’s Authorized Representative, if any; and  HPNSHL.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after  the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or  if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or,  if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after • the Member Insured has exhausted the all applicable internal HPN SHL Appeals Procedures provided under this Plan and or • if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal Appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or, Certificate of Coverage • if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN appeals proceduresapplicable SHL Appeals Procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN appeals processSHL Appeals Process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any • any medical records of the Member Insured relating to the adverse determination;  A • a copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  Any • any documents used and the reason(s) given by HPNSHL’s Managed Care Program for the adverse determination; and  If • if applicable, a list that specifies each Provider who provided healthcare to the Member Insured and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPNSHL, they shall notify the Member Insured or the MemberInsured’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN SHL within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member• Insured;  Member• Insured’s Physician;  Member• Insured’s Authorized Representative, if any; and  HPN• SHL.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after  the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or  if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, Agreement of Coverage  if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member relating to the adverse determination;  • A copy of the provisions of this Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after  the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or  if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or,  if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: Agreement of Coverage  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after • the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or • if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, • if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member relating to the adverse determination;  • A copy of the provisions of this Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after • the Member has exhausted the all applicable internal HPN Appeals Procedures provided under this Plan and or • if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal Appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, • if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals proceduresAppeals Procedures. In such event, the Member shall be considered to have exhausted the applicable internal HPN appeals processAppeals Process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member relating to the adverse determination;  • A copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.. Evidence of Coverage

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member relating to the adverse determination;  • A copy of the provisions of this Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

Standard External Review. The Member Insured or Insured’s Authorized Representative may submit a request for an External Review within four (4) months after receiving notice of an adverse determination under subject to this section only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue section, submit a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for an External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to All requests for standard external review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided made in writing to the IRO within five (5) days after receiving the requestOCHA. The IRO OCHA will forward a copy of the additional information to HPN notify SHL and/or any other interested parties within one (1) business day after receiptthe receipt of the request for External Review. Within five (5) business days after SHL receives such notice and, subject to applicable Nevada law and regulation and pursuant to this section, SHL will make a preliminary determination of whether the case is complete and eligible for External Review. Within one (1) business day of making such a determination, SHL will notify in writing, the Insured or the Insured’s Authorized Representative and OCHA, accordingly. If SHL determines that the case is incomplete and/or ineligible, SHL will notify the Insured in writing of such determination. Such notice shall include the required additional information or materials needed to make the request complete and, if applicable, state the reasons for ineligibility and also state that such determination may be appealed to OCHA. Upon appeal, OCHA may overturn SHL’s determination that a request for External Review of an adverse determination is ineligible, and submit the request to External Review, subject to all of the terms and provisions of this Plan and applicable Nevada law and regulation. Within one (1) business day after receiving the confirmation of eligibility for External Review from SHL, OCHA will assign the IRO accordingly and notify in writing the Insured or the Insured’s Authorized Representative and SHL that the request is complete and eligible for External Review and provide the name of the assigned IRO. SHL, within five (5) days after receipt of such notice from the OCHA, will supply all relevant medical documents and information used to establish the adverse determination to the assigned IRO who will select and assign one or more clinical reviewers to the External Review. The IRO shall approve, modify, or reverse the adverse determination pursuant to this section within fifteen twenty (1520) days after it receives the information required to make such a determination. The IRO Independent Review Organization shall submit a copy of its determination, including the basis thereof, to the:  Member• Insured;  Member• Insured’s Physician;  Member• Insured’s Authorized Representative, if any; and  HPN• SHL.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after  the Member has exhausted the all applicable internal HPN Appeals Procedures provided under this Plan and or  if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal Appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or,  if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals proceduresAppeals Procedures. In such event, the Member shall be considered to have exhausted the applicable internal HPN appeals processAppeals Process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.. Evidence of Coverage

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.and

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after  the Member Insured has exhausted the all applicable internal HPN SHL Appeals Procedures provided under this Plan and or  if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal Appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or,  if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN appeals proceduresapplicable SHL Appeals Procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN appeals processSHL Appeals Process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member Insured relating to the adverse determination;  A copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPNSHL’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.and

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after • the Member Insured has exhausted the internal HPN SHL Appeals Procedures provided under this Plan and or • if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or, • if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN SHL appeals procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN SHL appeals process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member Insured relating to the adverse determination;  • A copy of the provisions of this Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPNSHL’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member Insured and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPNSHL, they shall notify the Member Insured or the MemberInsured’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN SHL within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member• Insured;  Member• Insured’s Physician;  Member• Insured’s Authorized Representative, if any; and  HPN• SHL.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after • the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or • if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, • if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Agreement of Coverage • Any medical records of the Member relating to the adverse determination;  • A copy of the provisions of this Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after  the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and or  if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or,  if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Agreement of Coverage Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.