External Exception Review definition

External Exception Review. If an exception is not authorized for a non-formulary drug, a Member, a Member’s designee, or a prescribing physician may request a second level exception denial review by an external independent review. Organization (IRO) not legally affiliated with or controlled by KFHPWA. The IRO will provide its determination to the Member, Member designee and the prescribing physician no later than 72 hours of receipt of the request after receipt of information sufficient to make a decision. For expedited reviews, the IRO will provide a determination no later than 24 hours after the receipt of the request after receipt of information sufficient to make a decision.
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Examples of External Exception Review in a sentence

  • Submitting an External Exception Review does not preclude you from submitting a complaint with the Department of Managed Health Care.

  • When a member requests an External Exception Review, all records related to the request are forwarded to an Independent Review Organization that is unaffiliated with Scripps Health Plan.

  • External Exception Review: If the health plan denies an exception request for a non-formulary drug, the issuer must have a process for an enrollee, the enrollee’s designee, or the enrollee’s prescribing physician (or other prescriber, as appropriate) to request that an independent review organization review the exception request and the denial of that request by the plan.

  • When an enrollee requests an External Exception Review, all records related to the request are forwarded to an IRO that is contracted with but not part of your health plan.

  • If coverage is denied, KFHPWA will provide notification of the adverse determination to the prescribing physician and the member External Exception Review: If an exception is not authorized for a non-formulary drug, a Member, a Member’s designee, or a prescribing physician may request a second level exception denial review by an external independent review.

Related to External Exception Review

  • External inspection means an inspection that does not involve examination of the internal surfaces of the pressure parts of the boiler.

  • Internal inspection means as complete an examination as can be reasonably made of the internal and external surfaces of a boiler or pressure vessel while it is shut down and while manhole plates, handhole plates or other inspection opening closures are removed as required by the inspector.

  • External Review means an independent review of an Adverse Benefit Determination conducted by an Independent Review Organization.

  • Internal test assessment means, but is not limited to, conducting those tests of quality assurance necessary to ensure the integrity of the test.

  • Architectural Review Committee or “ARC” shall mean the architectural review committee established by the Organization to review plans submitted to the Organization for architectural review.

  • Independent testing laboratory means an independent organization, accepted by the Contracting Officer, engaged to perform specific inspections or tests of the work, either at the site or elsewhere, and report the results of these inspections or tests.

  • Utilization review plan or "plan" means a written procedure for performing review.

  • 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;

  • 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;

  • Peer support specialist means an individual who has experienced a severe and persistent mental illness and who has successfully completed standardized training to provide peer support services through the medical assistance program or the Iowa Behavioral Health Care Plan.

  • 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;

  • External beam radiation therapy means therapeutic irradiation in which the source of radiation is at a distance from the body.

  • Safeguards Monitoring Report means each report prepared and submitted by the Borrower to ADB that describes progress with implementation of and compliance with the EMP and the RP (as applicable), including any corrective and preventative actions;

  • independent review committee means the independent review committee of the investment fund established under National Instrument 81-107 Independent Review Committee for Investment Funds;

  • Independent Software Vendor or “ISV” means a Person that makes available to Participants and Authorized Traders a system or platform offering smart order routing, front-end trading applications, an aggregation platform or a combination of the foregoing but that does not provide Participants or Authorized Traders with the ability to effect transactions other than through the Trading System.

  • Root Cause Analysis Report means a report addressing a problem or non-conformance, in order to get to the ‘root cause’ of the problem, which thereby assists in correcting or eliminating the cause, and prevent the problem from recurring.

  • Evaluation Committee Report means a report prepared by the Procurement Manager and the Evaluation Committee for contract award. It will contain written determinations resulting from the procurement.

  • 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:

  • Toll Billing Exception Service (TBE means a service that allows End Users to restrict third number billing or collect calls to their lines.

  • Generally applicable environmental radiation standards means standards issued by the U.S. Environmental Protection Agency (EPA) under the authority of the Atomic Energy Act of 1954, as amended, that impose limits on radiation exposures or levels, or concentrations or quantities of radioactive material, in the general environment outside the boundaries of locations under the control of persons possessing or using radioactive material.

  • Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

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

  • Independent Verification means that an evaluation is undertaken and reported by an individual or body whose organisation, systems and procedures conform to ISO Guide 65:1996 (EN 45011:1998) General requirements for bodies operating product certification systems (as amended form time to time) or equivalent, and who is accredited to audit against forest management standards by a body whose organisation, systems and procedures conform to ISO 17011: 2004 General Requirements for Providing Assessment and Accreditation of Conformity Assessment Bodies (as amended from time to time) or equivalent.

  • Supervisory Review means ongoing clinical case reviews in accordance with procedures developed by ADMINISTRATOR, to determine the appropriateness of Diagnosis and treatment and to monitor compliance to the minimum ADMINISTRATOR and Medi-Cal charting standards. Supervisory review is conducted by the program/clinic director or designee.

  • Independent Auditors has the meaning set forth in Section 3.2.