Common use of Standard of Review Clause in Contracts

Standard of Review. Within 1 business day after the receipt of the notice of assignment to conduct the external review, the assigned IRO will select a Clinical Peer, or multiple Clinical Peers if medically appropriate under the circumstances, to conduct the external review. In selecting Clinical Peers to conduct the external review, the assigned IRO will select Physicians or other health care providers who meet minimum statutorily prescribed qualifications and who, through clinical experience in the past 3 years, are experts in the treatment of the Member’s condition and knowledgeable about the recommended or requested health care service or treatment. The choice of the Physicians or other health care providers to conduct the external review may not be made by the Member or the Member’s authorized representative or The Plan. Each Clinical Peer selected pursuant will review and consider all of the information and documents considered by The Plan in making the adverse benefit determination or the final internal Benefit determination and any other information submitted in writing by the Member or the Member’s authorized representative. Within 20 days after selection, each Clinical Peer will provide an opinion to the assigned IRO on whether the requested health care service or treatment should be covered. In reaching an opinion, Clinical Peers are not bound by any decisions or conclusions reached during The Plan’s internal appeals process. Each Clinical Xxxx's opinion will be in writing and include the following information: a. A description of the Member's medical condition; b. A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the requested health care service or treatment is more likely than not to be more beneficial to the Member than any available standard health care services or treatments and that the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments; c. A description and analysis of any Medical or Scientific Evidence considered in reaching the opinion; d. A description and analysis of any Evidence-Based Standard; and e. Information on whether the Clinical Peer's rationale for the opinion is based on the Member’s medical records and/or the attending provider’s or health care professional’s recommendation.