External Appeal definition

External Appeal means an appeal conducted by an External Appeal Agent pursuant to Section 4914 of the New York Insurance Law.
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External Appeal. An appeal, subsequent to the Contractor’s appeal decision, to the State Fair Hearing process for Medicaid-based adverse decisions.
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External Appeal means an appeal, subsequent to the participating plan appeal decision, to the state fair hearing process for Medicaid-based adverse decisions or to the Medicare process for Medicare-based adverse decisions. The department's external appeal decision shall be binding upon the participating plan and not subject to further appeal by the participating plan.
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Examples of External Appeal in a sentence

  • If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent.

  • In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application.

  • 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 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.

  • However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State.

  • 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.

  • If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeal sections of this Contract unless medical information is submitted.

  • The External Appeal Agent must also notify You in writing of its decision.

  • 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 Agent must notify You in writing of its decision within two (2) business days.


More Definitions of External Appeal

External Appeal. A Member or authorized representative has the right to request a second level external appeal from DIFS within sixty (60) days of receipt of the decision from the first level internal appeal. The Member or authorized representative initiates the external appeal request by filing the DIFS Health Care Request for External Review Form within sixty (60) days. A copy of the Health Care Request for External Review Form will be included with the final decision letter from the first level internal appeal. Members may also call DIFS at (000) 000-0000 to receive the form via US mail. When appropriate, DIFS will request a recommendation by an independent review organization. The independent review organization is not a part of the Plan. The Commissioner of DIFS will issue a final order which then exhausts the Member’s appeal right. To ask questions about the external review process, contact the Total Health Care, USA Grievance Coordinator at (313) 571-6583 or (000) 000-0000 x000 or write: Department of Insurance and Financial Services Healthcare Appeals Section, Office of General Counsel P.O. Box 30220 Lansing, Michigan 00000-0000 Or call: (000) 000-0000 Or fax: (000) 000-0000
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External Appeal means an appeal, subsequent to the participating plan internal appeal or reconsideration decision, to the state fair hearing process (for a member appeal) or informal appeals process (for a provider appeal).
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External Appeal means a request for an independent, external review of the final Adverse Determination made by Anthem through its internal appeal process.
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External Appeal means an appeal, subsequent to the participating plan internal appeal or reconsideration decision, to the state fair hearing process or internal reconsideration process for adverse decisions. The department's external appeal decision shall be binding upon the participating plan or plans and not subject to further appeal by the participating plan or plans.
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Related to External Appeal

  • Internal appeal means an internal appeal to the relevant authority in terms of section 74;

  • External Auditor as used here shall mean any registered public accounting firm engaged for the purpose of preparing or issuing an audit report or performing other audit, review or attest services for the Company. Each such external auditor shall report directly to the Committee. With respect to the external auditor, the Committee shall:

  • External Account is your account at another financial institution (i) to which you are transferring funds from your Eligible Transaction Account; or (ii) from which you are transferring funds to your Eligible Transaction Account.

  • External dose means that portion of the dose equivalent received from any source of radiation outside the body.

  • Internal Auditor means the person employed or engaged by the Corporation to perform the internal audit function of the Corporation;

  • external borders means external borders as defined in point 2 of Article 2 of Regulation (EU) 2016/399;

  • Internal dose means that portion of the dose equivalent received from radioactive material taken into the body.

  • Internal Procedures means in respect of the making of any one or more entries to, changes in or deletions of any one or more entries in the register at any time (including without limitation, original issuance or registration of transfer of ownership) the minimum number of the Warrant Agent’s internal procedures customary at such time for the entry, change or deletion made to be complete under the operating procedures followed at the time by the Warrant Agent, it being understood that neither preparation and issuance shall constitute part of such procedures for any purpose of this definition;

  • External Manager means either of the following: (1) A person who is seeking to be, or is, retained by a board or an investment vehicle to manage a portfolio of securities or other assets for compensation, or (2) A person who manages an investment fund and who offers or sells, or has offered or sold, an ownership interest in the investment fund to a board or an investment vehicle.

  • Automated external defibrillator or “AED” means an external semiautomatic device that determines whether defibrillation is required.

  • External Verifier means any qualified provider of third party assurance or attestation services or other independent expert of internationally recognised standing appointed by the Issuer, in each case with the expertise necessary to perform the functions required to be performed by the External Verifier under these Conditions, as determined in good faith by the Issuer;

  • internal waters means any navigable river or waterway within the State of California.

  • external engineering service means an engineering service situated outside the boundaries of a land area and that is necessary to serve the use and development of the land area;

  • Internal Controls for districts means processes designed and im- plemented by districts to provide reasonable assurance regarding the achievement of objectives in the following categories:

  • External Directors means as defined in the Companies Law.

  • Internal combustion engine or ‘engine’ means an energy converter, other than a gas turbine, designed to transform chemical energy (input) into mechanical energy (output) with an internal combustion process; it includes, where they have been installed, the emission control system and the communication interface (hardware and messages) between the engine's electronic control unit(s) and any other powertrain or non-road mobile machinery control unit necessary to comply with Chapters II and III;

  • Engineering controls means constructed containment barriers or systems that control one or more of the following: downward migration, infiltration, or seepage of surface runoff or rain; or natural leaching migration of contaminants through the subsurface over time. Examples include caps, engineered bottom barriers, immobilization processes, and vertical barriers.

  • Interim controls means a set of measures designed to temporarily reduce human exposure or likely exposure to lead-based paint hazards, including specialized cleaning, repairs, maintenance, painting, temporary containment, ongoing monitoring of lead-based paint hazards or potential hazards, and the establishment and operation of management and resident education programs.