Common use of Timeframes for Internal Review of Adverse Determinations Clause in Contracts

Timeframes for Internal Review of Adverse Determinations. Upon receipt of a request for internal review of an Adverse Determination, we shall conduct either a standard or expedited review, as appropriate.  Expedited review. We shall complete our internal review as required by the medical exigencies of the case but in no case later than seventy-two (72) hours from the time the internal review request was received whenever:  Your life or health would be jeopardized.  Your ability to regain maximum function would be jeopardized.  The Practitioner/Provider reasonably requests an expedited decision.  In the opinion of the Practitioner/Provider with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim or  The medical exigencies of the case require an expedited decision.  Standard review. We shall complete a standard review of both internal reviews as described in state laws within twenty (20) working days of receipt of the request for internal review in all cases in which the request for review is made prior to the service requested, and does not require expedited review, and within forty (40) working days of receipt of the request in all post-service requests for internal review. We may extend the review period for a maximum of ten (10) working days in pre-service cases, and twenty (20) working days for post-service cases if we:  can demonstrate reasonable cause beyond its control for the delay,  can demonstrate that the delay will not result in increased medical risk to you and  provide a written progress report and explanation for the delay to your Practitioner/Provider within the original thirty (30) days for pre-service or sixty (60) days for post-service review period,  if the Grievance contains clearly divisible Administrative and Adverse Decision issues, then we shall initiate separate complaints for each decision.  Failure to comply with deadline. If we fail to comply with the deadline for completion of an internal review, the requested Health Care Service shall be deemed approved unless you, after being fully informed of your rights, have agreed in writing to extend the deadline. Internal Panel Review of Adverse Determinations  Selection of an internal review panel. In cases of Appeal from an Adverse Determination or from a third party administrator’s decision to uphold an Adverse Determination, we shall select an internal review panel to review the Adverse Determination or the decision to uphold the Adverse Determination.

Timeframes for Internal Review of Adverse Determinations. Upon receipt of a request for internal review of an Adverse Determination, we shall conduct either a standard or expedited review, as appropriate.  ⮚ Expedited review. We shall complete our internal review as required by the medical exigencies of the case but in no case later than seventy-two (72) hours from the time the internal review request was received whenever:  • Your life or health would be jeopardized.  • Your ability to regain maximum function would be jeopardized.  • The Practitioner/Provider reasonably requests an expedited decision.  • In the opinion of the Practitioner/Provider with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim or  • The medical exigencies of the case require an expedited decision.  ⮚ Standard review. We shall complete a standard review of both internal reviews as described in state laws within twenty (20) working days of receipt of the request for internal review in all cases in which the request for review is made prior to the service requested, and does not require expedited review, and within forty (40) working days of receipt of the request in all post-service requests for internal review. We may extend the review period for a maximum of ten (10) working days in pre-service cases, and twenty (20) working days for post-service cases if we:  • can demonstrate reasonable cause beyond its control for the delay,  • can demonstrate that the delay will not result in increased medical risk to you and  • provide a written progress report and explanation for the delay to your Practitioner/Provider within the original thirty (30) days for pre-service or sixty (60) days for post-service review period,  • if the Grievance contains clearly divisible Administrative and Adverse Decision issues, then we shall initiate separate complaints for each decision.  ⮚ Failure to comply with deadline. If we fail to comply with the deadline for completion of an internal review, the requested Health Care Service shall be deemed approved unless you, after being fully informed of your rights, have agreed in writing to extend the deadline. Internal Panel Review of Adverse Determinations  ⮚ Selection of an internal review panel. In cases of Appeal from an Adverse Determination or from a third party administrator’s decision to uphold an Adverse Determination, we shall select an internal review panel to review the Adverse Determination or the decision to uphold the Adverse Determination.

Timeframes for Internal Review of Adverse Determinations. Upon receipt of a request for internal review of an Adverse Determination, we shall conduct either a standard or expedited review, as appropriate.  Expedited review. We shall complete our internal review as required by the medical exigencies of the case but in no case later than seventy-two (72) hours from the time the internal review request was received whenever:  Your life or health would be jeopardized.  Your ability to regain maximum function would be jeopardized.  The Practitioner/Provider reasonably requests an expedited decision.  In the opinion of the Practitioner/Provider with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim or  The medical exigencies of the case require an expedited decision.  Standard review. We shall complete a standard review of both internal reviews as described in state laws within twenty (20) working days of receipt of the request for internal review in all cases in which the request for review is made prior to the service requested, and does not require expedited review, and within forty (40) working days of receipt of the request in all post-service requests for internal review. We may extend the review period for a maximum of ten (10) working days in pre-service cases, and twenty (20) working days for post-service cases if we:  can demonstrate reasonable cause beyond its control for the delay,  can demonstrate that the delay will not result in increased medical risk to you and  provide a written progress report and explanation for the delay to your Practitioner/Provider within the original thirty (30) days for pre-service or sixty (60) days for post-service review period,  if the Grievance contains clearly divisible Administrative and Adverse Decision issues, then we shall initiate separate complaints for each decision.  Failure to comply with deadline. If we fail to comply with the deadline for completion of an internal review, the requested Health Care Service shall be deemed approved unless you, after being fully informed of your rights, have agreed in writing to extend the deadline. First and Second Internal Panel Review of Adverse Determinations for Group Health Plans  Selection Applicability. This section applies only to our Group Health Care Benefits Plans and entities subject to the Health Care Purchasing Act that conduct the first level of an the internal Appeal, and to Health Care Insurers who offer Group Health Care Benefits Plans that conduct the second level of the internal Appeal.  Scope of review. Health Care Insurers that offer Group Health Care Benefits Plans and entities subject to the Health Care Purchasing Act shall complete the review panel. In cases of Appeal from an Adverse Determination or from a third party administrator’s decision to uphold an Adverse Determination, we shall select an internal review panel to review the Adverse Determination or within the decision to uphold the Adverse Determinationtimeframes established in state law.