Common use of Your Right to an External Appeal Clause in Contracts

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract Policy; and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract Contract; and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care care, or effectiveness of a Covered covered benefit); ) or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), ) or is an out-of-network treatment. You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: •  The service, procedure, or treatment must otherwise be a Covered Service under this Contract Policy and •  In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is does not Medically Necessary meet Our requirements for Medical Necessity (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirementsrequirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract the Contract; and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract Contract; and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο : 1. We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο or 2. You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο or 3. We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: •  The service, procedure, or treatment must otherwise be a Covered Service under this Contract Certificate; and •  In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: •  The service, procedure, or treatment must otherwise be a Covered Service under this Contract Policy; and •  In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals. In order for You to be eligible for an external appeal You must meet the following two (2)requirements2) requirements: •  The service, procedure, or treatment must otherwise be a Covered Service under this Contract Contract; and •  In general, You must have received a final adverse determination through Our internal Appeal process. But, But You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: ο o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or ο o You file an external appeal at the same time as You apply for an expedited internal Appeal; or ο o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).