Common use of Standard of Review Clause in Contracts

Standard of Review. In reaching its decision, the IRO will review the claim and will not be bound by any decisions or conclusions reached under The Plan’s internal claims and appeals process. In addition to the documents and information timely received, and to the extent the information or documents are available, the IRO will consider the following in reaching a decision: a. The Member’s medical records; b. The Member’s treating provider(s)’s recommendations; c. Reports from appropriate health care professionals and other documents, opinions, and recommendations submitted by The Plan and the Member; d. The terms and conditions of The Plan, including specific coverage provisions, to ensure that the IRO’s decision is not contrary to the terms and conditions of The Plan, unless the terms and conditions do not comply with applicable law; e. Appropriate practice guidelines, which must include applicable Evidence-Based Standards; f. Any applicable clinical review criteria developed and used by The Plan unless the criteria are inconsistent with the terms and conditions of The Plan or do not comply with applicable law; g. The applicable Medical Policies of The Plan; and/or h. The opinion of the IRO’s clinical reviewer or reviewers after considering information described in this notice to the extent the information or documents are available, and the clinical reviewer or reviewers consider them appropriate.