Written Notice of the IRO’s Final External Review Decision. Within 48 hours after the date of receiving the opinion of each Clinical Peer, the IRO shall make a decision based upon the recommendations of a majority of the Clinical Peers conducting the review and will provide oral or written notice of the decision to the Member or the Member’s authorized representative and to The Plan. If the IRO’s notice is provided orally, the IRO will provide written confirmation of the decision within 48 hours of the initial oral notice. The IRO will include in its written notice:
a. A general description of the reason for the request for external review;
b. The written opinion of each Clinical Peer, including the opinion of each Clinical Peer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer's recommendation;
c. The date on which the IRO was assigned to conduct the external review;
d. The date of the IRO's decision; and
e. The principal rationale for the IRO’s decision.
Written Notice of the IRO’s Final External Review Decision. Within 20 days after the date of receiving the opinion of each Clinical Peer, the IRO shall make a decision and provide written notice of the decision to the Member or the Member’s authorized representative and to The Plan. If a majority of the Clinical Peers respond that the recommended or requested health care service or treatment should be covered, the IRO shall make a decision to reverse The Plan's adverse benefit determination or final internal adverse benefit determination. If a majority of the Clinical Peers respond that the recommended or requested health care service or treatment should not be covered, the IRO shall make a decision to uphold The Plan's adverse benefit determination or final internal adverse benefit determination. If the Clinical Peers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the IRO shall obtain the opinion of an additional Clinical Peer. The additional Clinical Peer shall use the same information to reach an opinion as used by the Clinical Peers who have already submitted their opinions. The selection of the additional Clinical may not extend the time within which the assigned IRO is required to make a decision based on the opinions of the Clinical Peers. The IRO will include in its written notice:
a. A general description of the reason for the request for external review;
b. The written opinion of each Clinical Peer, including the opinion of each Clinical Peer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer's recommendation;
c. The date on which the IRO was assigned to conduct the external review;
d. The date of the IRO's decision; and
e. The principal rationale for the IRO’s decision.
Written Notice of the IRO’s Final External Review Decision. The IRO will send written notification of its decision to the Member and to The Plan within 45 days after the IRO’s receipt of the request for external review. The notice will include:
a. A general description of the reason for the external review request, including information sufficient to identify the claim, and the reason for the prior denial;
b. The date the IRO received the assignment to conduct the external review and the date of the IRO’s decision;
c. References to the evidence or documentation considered in reaching the decision, including specific coverage provisions and Evidence-Based Standards;
d. A discussion of the principal reason(s) for the IRO’s decision, including the rationale for its decision and any Evidence-Based Standards relied on in making the decision;
e. A statement that the IRO’s determination is binding, unless other remedies are available to The Plan or the Member under state or federal law;
f. A statement that judicial review may be available to the Member and The Plan; and
g. Contact information for a consumer appeal assistance program at the Commissioner of Securities and Insurance. 18
