Common use of The External Appeal Process Clause in Contracts

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that would not be Covered under this Contract for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that would not be Covered under this Contract for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-non- health care services, the costs of managing the research, or costs that would not be Covered under this Contract for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You A. If, through Fidelis’ internal appeal process, you have received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process such notice to file a written request for an external appeal. If You are filing an external appeal based on Our failure you and Fidelis have agreed in writing to adhere to claim processing requirementswaive any internal appeal, You you have four forty-five (445) months days from such failure to file a written request for an external appeal. We Fidelis will provide an external appeal application with the final adverse determination issued through Our Fidelis’ internal Appeal appeal process or Our its written waiver of an internal Appeal. appeal. B. You may also request an external appeal application from the New York State Department of Financial Services at 01-000800- 400-000-00008882. Submit the completed application to the State Department of Financial Services Insurance at the address indicated on the application. If You meet you satisfy the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. . C. You can will have the opportunity to submit additional documentation with Your external appeal your request. If the External Appeal Agent determines that the information You you submit represents a material change from the information on which We Fidelis based Our its denial, the External Appeal Agent will share this information with Us Fidelis in order for Us it to exercise Our its right to reconsider Our its decision. . D. If We choose Fidelis chooses to exercise this right, We Fidelis will have three (3) business days to amend or confirm Our its decision. Please note that in the case of an expedited external appeal (described below); We do , Fidelis does not have a right to reconsider Our its decision. . E. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your your completed application. The External Appeal Agent may request additional information from Youyou, Your Physician, your physician or UsFidelis. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You you in writing of its decision within two (2) business days. . F. If Your your attending Physician physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You you may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours three (3) days of receipt of Your your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also try to notify You in writing of its you and Fidelis by telephone or facsimile immediately after reaching a decision. . G. If the External Appeal Agent overturns Our Fidelis’ decision that a service is not Medically Necessary medically necessary or approves coverage of an experimental or investigational treatment, We Fidelis will provide coverage subject to the other terms and conditions of this Subscriber Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We Fidelis will only Cover cover the cost costs of services required to provide treatment to You you according to the design of the trial. We will Fidelis shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that which would not be Covered covered under this Subscriber Contract for non-experimental or non-investigational treatments provided in the such clinical trial. . H. The External Appeal Agent’s decision is binding on both You you and UsFidelis. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this ContractPolicy. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that would not be Covered under this Contract Policy for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-non- health care services, the costs of managing the research, or costs that would not be Covered under this Contract for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of If, through Our internal appeal process, the Insured Person has received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, the Insured Person has forty-five (45) days from receipt of a waiver of the internal Appeal process such notice to file a written request for an external appeal. If You are filing an external appeal based on Our failure We and the Insured Person have agreed in writing to adhere to claim processing requirementswaive any internal appeal, You have four the Insured Person has forty-five (445) months days from receipt of such failure waiver to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal appeal process or Our written waiver of an internal Appealappeal. You The Insured Person may also request an external appeal application from the New York State Insurance Department of Financial Services at 0-000-000-0000. Submit the completed application to the Insurance Department of Financial Services at the address indicated on the application. If You meet the Insured Person satisfies the criteria for an external appeal, the State will forward the request to a certified External Appeal Agentexternal appeal agent. You can The Insured Person will have an opportunity to submit additional documentation with Your external appeal his or her request. If the External Appeal Agent external appeal agent determines that the information You submit submitted represents a material change from the information on which We based Our denial, the External Appeal Agent external appeal agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent external appeal agent must make a decision within 30 thirty (30) days of receipt of Your the Insured Person's completed application. The External Appeal Agent external appeal agent may request additional information from Youthe Insured Person, Your Physicianthe Insured Person's physician, or Us. If the External Appeal Agent external appeal agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent external appeal agent must notify You the Insured Person in writing of its decision within two (2) business days. If Your the Insured Person's attending Physician physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your such Insured Person's health; or if Your attending Physician certifies that , the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You Insured Person may request an expedited external appeal. In that case, the External Appeal Agent external appeal agent must make a decision within 72 hours three (3) days of receipt of Your the completed application. Immediately after reaching a decision, the External Appeal Agent external appeal agent must try to notify You the Insured Person and Us by telephone or facsimile of that decision. The External Appeal Agent external appeal agent must also notify You the Insured Person in writing of its decision. If the External Appeal Agent external appeal agent overturns Our decision that a service is not Medically Necessary medically necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this ContractPolicy. Please note that if the External Appeal Agent external appeal agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover cover the cost costs of services required to provide treatment to You the Insured Person according to the design of the trial. We will shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that which would not be Covered covered under this Contract subscriber contract for non-experimental or non-investigational treatments provided in the such clinical trial. The External Appeal Agent’s external appeal agent's decision is binding on both You the Insured Person and Us. The External Appeal Agent’s external appeal agent's decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment or an out-of-network treatment, We will provide coverage subject to the other terms and conditions of this ContractPolicy. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost costs of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that would not be Covered under this Contract Policy for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that would not be Covered under this Contract for non-non- investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You If, through the Plan’s internal appeal process, you have four (4) received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you have 4 months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process such notice to file a written request for an external appeal. If You are filing an external appeal based on Our failure you and the Plan have agreed in writing to adhere to claim processing requirementswaive any internal appeal, You you have four (4) 4 months from receipt of such failure waiver to file a written request for an external appeal. We The Plan will provide an external appeal application with the final adverse determination issued through Our the Plan’s internal Appeal appeal process or Our its written waiver of an internal Appealappeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the State Department of Financial Services Insurance at the address indicated on the application. If You meet you satisfy the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can will have the opportunity to submit additional documentation with Your external appeal your request. If the External Appeal Agent determines that the information You you submit represents a material change from the information on which We the Plan based Our its denial, the External Appeal Agent will share this information with Us the Plan in order for Us it to exercise Our its right to reconsider Our its decision. If We choose the Plan chooses to exercise this right, We the Plan will have three (3) business days to amend or confirm Our its decision. Please note that in the case of an expedited external appeal (described below); We do , the Plan does not have a right to reconsider Our its decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your your completed application. The External Appeal Agent may request additional information from Youyou, Your Physician, your physician or Usthe Plan. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You you in writing of its decision within two (2) business days. If Your your attending Physician physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You you may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours three (3) days of receipt of Your your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also try to notify You in writing of its you and the Plan by telephone or facsimile immediately after reaching a decision. If the External Appeal Agent overturns Our the Plan’s decision that a service is not Medically Necessary medically necessary or approves coverage of an experimental or investigational treatment, We the Plan will provide coverage subject to the other terms and conditions of this Subscriber Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We the Plan will only Cover cover the cost costs of services required to provide treatment to You you according to the design of the trial. We will The Plan shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that which would not be Covered covered under this Subscriber Contract for non-experimental or non-investigational treatments provided in the such clinical trial. The External Appeal Agent’s decision is binding on both You you and Usthe Plan. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 seventy-two (72) hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-non- health care services, the costs of managing the research, or costs that would not be Covered under this Contract for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

The External Appeal Process. You have four (4) months from receipt of a final adverse determination or from receipt of a waiver of the internal Appeal process to file a written request for an external appeal. If You are filing an external appeal based on Our failure to adhere to claim processing requirements, You have four (4) months from such failure to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our internal Appeal process or Our written waiver of an internal Appeal. You may also request an external appeal application from the New York State Department of Financial Services at 0-000-000-0000. Submit the completed application to the Department of Financial Services at the address indicated on the application. If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can submit additional documentation with Your external appeal request. If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision. If We choose to exercise this right, We will have three (3) business days to amend or confirm Our decision. Please note that in the case of an expedited external appeal (described below); , We do not have a right to reconsider Our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application. The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You in writing of its decision within two (2) business days. If Your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility facility and the denial concerns an admission, availability of care, or continued stay, You may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also notify You in writing of its decision. If the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment or an out-of-network treatment, We will provide coverage subject to the other terms and conditions of this ContractCertificate. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial. We will not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that would not be Covered under this Contract Certificate for non-investigational treatments provided in the clinical trial. The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding. We will charge You a fee of $25 for each external appeal, not to exceed $75 in a single Plan Year. The external appeal application will explain how to submit the fee. We will waive the fee if We determine that paying the fee would be a hardship to You. If the External Appeal Agent overturns the denial of coverage, the fee will be refunded to You.

The External Appeal Process. You If, through the first level of our internal appeal process, you have four (4) months from receipt of received a final adverse determination upholding a denial of coverage on the basis that the service is not Medically Necessary or is an experimental or investigational treatment, you have forty-five (45) days from receipt of a waiver of the internal Appeal process such notice to file a written request for an external appeal. If You are filing an external appeal based on Our failure we both have agreed in writing to adhere to claim processing requirementswaive any internal appeal, You you have four forty-five (445) months days from receipt of such failure waiver to file a written request for an external appeal. We will provide an external appeal application with the final adverse determination issued through Our the first level of our internal Appeal appeal process or Our our written waiver of an internal Appealappeal. You may also request an external appeal application from the New York State Department of Financial Services at 01-000800-000-0000400- 8882. Submit the completed application to the New York State Insurance Department of Financial Services at the address indicated on the application. If You meet you satisfy the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent. You can will have the opportunity to submit additional documentation with Your external appeal your request. If the External Appeal Agent determines that the information You you submit represents a material change from the information on which We we based Our our denial, the External Appeal Agent will share this information with Us us in order for Us us to exercise Our our right to reconsider Our our decision. If We we choose to exercise this right, We we will have three (3) business days to amend or confirm Our our decision. Please note that in the case of an expedited external appeal (described below); We , we do not have a right to reconsider Our our decision. In general, the External Appeal Agent must make a decision within 30 thirty (30) days of receipt of Your your completed application. The External Appeal Agent may request additional information from Youyou, Your Physician, your physician or Usfrom us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify You you in writing of its decision within two (2) business days. If Your your attending Physician physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to Your your health; or if Your attending Physician certifies that the standard external appeal time frame would seriously jeopardize Your life, health or ability to regain maximum function; or if You received emergency services and have not been discharged from a Facility and the denial concerns an admission, availability of care, or continued stay, You you may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours three (3) days of receipt of Your your completed application. Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision. The External Appeal Agent must also try to notify You in writing of its you and us by telephone or facsimile immediately after reaching a decision. If the External Appeal Agent overturns Our our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We we will provide coverage subject to the other terms and conditions of this Contract. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We we will only Cover cover the cost costs of services required to provide treatment to You you according to the design of the trial. We will shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing the research, or costs that which would not be Covered covered under this Contract for non-experimental or non-investigational treatments provided in the such clinical trial. The External Appeal Agent’s decision is binding on both You you and Usus. The External Appeal Agent’s decision is admissible in any court proceeding. We will charge you a fee of fifty dollars ($50.00) for an external appeal. The external appeal application will instruct you on the manner in which you must submit the fee. We will waive the fee if we determine that paying the fee would pose a hardship for you. If the External Appeal Agent overturns the denial of coverage, the fee shall be refunded to you.