2nd Level Formal Appeal Sample Clauses

2nd Level Formal Appeal. When a 1st Level Formal Appeal is not resolved in a manner that is satisfactory to the Member, the Member may initiate a 2nd Level Formal Appeal. This appeal must be submitted orally or in writing within thirty (30) days after the Member has been informed of the resolution of the 1st Level Formal Appeal. Exhaustion of the 1st Level Formal Appeal procedure is a precondition to filing a 2nd Level Formal Appeal. A 2nd Level Formal Appeal not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which it relates. The 2nd Level Formal Appeal is voluntary for all Pre-Service and Post-Service Claims for Benefits. Expedited appeals are not eligible for 2nd Level Formal Appeal. Expedited appeals may be processed through the Expedited External Review process. Please reference Expedited External Review of this plan document. The notice to the Member or the Member’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the 2nd Level Formal Appeal and • any other forms as required by Nevada law or regulation.
Sample 1
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2nd Level Formal Appeal. If a 1st Level Formal Appeal is not resolved to the Member’s satisfaction, a Member may then file a 2nd Level Formal Appeal. A 2nd Level Formal Appeal is submitted either orally or in writing and reviewed by the Grievance Review Committee. The 2nd Level Formal Appeal is voluntary for all Adverse Benefit Determinations. Appeals that meet expedite criteria are not eligible for 2nd Level Formal Appeal and may be processed through the Expedited External Review process.
Sample 1
2nd Level Formal Appeal. If a 1st Level Formal Appeal is not resolved to the Insured’s satisfaction, an Insured may then file a 2nd
Sample 1
2nd Level Formal Appeal. When a 1st Level Formal Appeal is not resolved in a manner that is satisfactory to the Insured, the Insured may initiate a 2nd Level Formal Appeal. This appeal must be submitted in writing within thirty (30) days after the Insured has been informed of the resolution of the 1st Level Formal Appeal. Exhaustion of the 1st Level Formal Appeal procedure is a precondition to filing a 2nd Level Formal Appeal. A 2nd Level Formal Appeal not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which it relates. The 2nd Level Formal Appeal is voluntary for all Pre-Service, Post-Service, and Urgent Care Claims for Benefits. Adverse determinations eligible for Expedited 2nd Level Formal Appeals set forth in this section are only those relating to Pre-Service Claims related to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. The Insured has forty-eight (48) hours to request an Expedited 2nd Level Formal Appeal from the date of the notification of the Adverse Determination. Expedited 2nd Level Formal Appeals must be decided no later than seventy-two (72) hours after receipt of the Expedited 2nd Level Formal Appeal, provided all necessary information has been submitted to SHL. If the initial notification was oral, SHL shall provide a written or electronic explanation to the Insured seventy-two (72) hours after the expedited appeal being filed.
Sample 1
2nd Level Formal Appeal. When a 1st Level Formal Appeal is not resolved in a manner that is satisfactory to the Insured, the Insured may initiate a 2nd Level Formal Appeal. This appeal must be submitted orally or in writing within thirty (30) days after the Insured has been informed of the resolution of the 1st Level Formal Appeal.
Sample 1

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