Common use of Adverse Determination Clause in Contracts

Adverse Determination. The IRO shall provide notice of its decision to uphold or reverse the Adverse Determination or Final Adverse Determination to the Plan, the Director and you: as expeditiously as your medical condition or circumstances require, but no more than 72 hours after the receipt of request. External Review of Experimental or Investigational Treatment Experimental or Investigational Treatment External Review Timing You may file a request with the Director for an external review after receipt of an Adverse Determination or a Final Adverse Determination within: 4 months after date of receipt If your treating Physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, you may make an oral request for an expedited external review, after which the Director shall immediately notify the Plan and the time frames otherwise applicable to Expedited External Review shall apply. After the receipt for an external review, the Director shall send a copy of the request to the Plan within: one business day The Plan shall complete a preliminary review of the request within: 5 business days After completion of the preliminary review, the Plan shall notify you and the Director whether the request is complete and eligible for external review within: one business day When the Director receives notice that the request is eligible for external review, the Director shall: assign an IRO and notify the Plan of the name of the IRO, within: one business day notify you of the request's eligibility and acceptance for external review and the name of the IRO, within: one business day If you are notified that your request for an external review has been accepted, you must submit additional information to the assigned IRO within: 5 business days The assigned IRO shall then select one or more clinical reviewers within: one business day The Plan shall provide to the assigned IRO the documents and any information used in making the Adverse Determination or Final Adverse Determination within: 5 business days of notice of assigned IRO After being selected by the assigned IRO, each clinical reviewer shall provide an opinion to the assigned IRO on whether the recommended or request health care service shall be covered within: 20 days Experimental or Investigational Treatment External Review Timing or, in the case of an expedited external review: immediately, but in no event more than 5 calendar days The assigned IRO shall make a decision after receipt of the opinion from each clinical reviewer and provide notification of the decision to the Director, you and the Plan within: 20 days or, in the case of an expedited external review, within: 48 hours after receipt of the opinion of each clinical reviewer OTHER THINGS YOU SHOULD KNOW REIMBURSEMENT PROVISION If you or one of your covered dependents incur expenses for sickness or injury that occurred due to the negligence of a third party and benefits have been pro­ vided for Covered Services described in this Policy, you agree:

Adverse Determination. The IRO shall provide notice of its decision to uphold or reverse the Adverse Determination or Final Adverse Determination to the Plan, the Director and you: as expeditiously as your medical condition or circumstances require, but no more than 72 hours after the receipt of request. External Review of Experimental or Investigational Treatment Experimental or Investigational Treatment External Review Timing You may file a request with the Director for an external review after receipt of an Adverse Determination or a Final Adverse Determination within: 4 months after date of receipt If your treating Physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, you may make an oral request for an expedited external review, after which the Director shall immediately notify the Plan and the time frames otherwise applicable to Expedited External Review shall apply. After the receipt for an external review, the Director shall send a copy of the request to the Plan within: one business day The Plan shall complete a preliminary review of the request within: 5 business days Experimental or Investigational Treatment External Review Timing After completion of the preliminary review, the Plan shall notify you and the Director whether the request is complete and eligible for external review within: one business day When the Director receives notice that the request is eligible for external review, the Director shall: assign an IRO and notify the Plan of the name of the IRO, within: one business day notify you of the request's eligibility and acceptance for external review and the name of the IRO, within: one business day If you are notified that your request for an external review has been accepted, you must submit additional information to the assigned IRO within: 5 business days The assigned IRO shall then select one or more clinical reviewers within: one business day The Plan shall provide to the assigned IRO the documents and any information used in making the Adverse Determination or Final Adverse Determination within: 5 business days of notice of assigned IRO After being selected by the assigned IRO, each clinical reviewer shall provide an opinion to the assigned IRO on whether the recommended or request health care service shall be covered within: 20 days Experimental or Investigational Treatment External Review Timing or, in the case of an expedited external review: immediately, but in no event more than 5 calendar days The assigned IRO shall make a decision after receipt of the opinion from each clinical reviewer and provide notification of the decision to the Director, you and the Plan within: 20 days or, in the case of an expedited external review, within: 48 hours after receipt of the opinion of each clinical reviewer OTHER THINGS YOU SHOULD KNOW REIMBURSEMENT PROVISION If you or one of your covered dependents incur expenses for sickness or injury that occurred due to the negligence of a third party and benefits have been pro­ vided for Covered Services described in this Policy, you agree:days

Adverse Determination. The IRO shall provide notice of its decision to uphold or reverse the Adverse Determination or Final Adverse Determination to the Plan, the Director IDOI and youyou or your authorized representative: as expeditiously as your medical condition or circumstances require, but no more than 72 hours after the receipt of request. External Review of Experimental or Investigational Treatment Experimental or Investigational Treatment External Review Timing You may file a request with the Director IDOI for an external review after receipt of an Adverse Determination or a Final Adverse Determination within: 4 months after date of receipt If your treating Physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, you may make an oral request for an expedited external review, after which the Director IDOI shall immediately notify the Plan and the time frames otherwise applicable to Expedited External Review shall apply. After the receipt for an external review, the Director IDOI shall send a copy of the request to the Plan within: one business day The Plan shall complete a preliminary review of the request within: 5 business days After completion of the preliminary review, the Plan shall notify you or your authorized representative and the Director IDOI whether the request is complete and eligible for external review within: one business day When the Director IDOI receives notice that the request is eligible for external review, the Director IDOI shall: assign an IRO and notify the Plan of the name of the IRO, within: one business day notify you of the request's eligibility and acceptance for external review and the name of the IRO, within: one business day If you are notified that your request for an external review has been accepted, you must submit additional information to the assigned IRO within: 5 business days The assigned IRO shall then select one or more clinical reviewers within: one business day The Plan shall provide to the assigned IRO the documents and any information used in making the Adverse Determination or Final Adverse Determination within: 5 business days of notice of assigned IRO After being selected by the assigned IRO, each clinical reviewer shall provide an opinion to the assigned IRO on whether the recommended or request health care service shall be covered within: 20 days Experimental or Investigational Treatment External Review Timing or, in the case of an expedited external review: immediately, but in no event more than 5 calendar days The assigned IRO shall make a decision after receipt of the opinion from each clinical reviewer and provide notification of the decision to the Director, you and the Plan within: 20 days or, in the case of an expedited external review, within: 48 hours after receipt of the opinion of each clinical reviewer OTHER THINGS YOU SHOULD KNOW REIMBURSEMENT PROVISION If you or one of your covered dependents incur expenses for sickness or injury that occurred due to the negligence of a third party and benefits have been pro­ vided for Covered Services described in this Policy, you agree:day

Adverse Determination. The IRO shall provide notice of its decision to uphold or reverse the Adverse Determination or Final Adverse Determination to the Plan, the Director IDOI and youyou or your authorized representative: as expeditiously as your medical condition or circumstances require, but no more than 72 hours after the receipt of request. External Review of Experimental or Investigational Treatment Experimental or Investigational Treatment External Review Timing You may file a request with the Director IDOI for an external review after receipt of an Adverse Determination or a Final Adverse Determination within: 4 months after date of receipt If your treating Physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, you may make an oral request for an expedited external review, after which the Director IDOI shall immediately notify the Plan and the time frames otherwise applicable to Expedited External Review shall apply. After the receipt for an external review, the Director IDOI shall send a copy of the request to the Plan within: one business day The Plan shall complete a preliminary review of the request within: 5 business days After completion of the preliminary review, the Plan shall notify you or your authorized representative and the Director IDOI whether the request is complete and eligible for external review within: one business day When the Director IDOI receives notice that the request is eligible for external review, the Director IDOI shall: assign an IRO and notify the Plan of the name of the IRO, within: one business day notify you of the request's eligibility and acceptance for external review and the name of the IRO, within: one business day If you are notified that your request for an external review has been accepted, you must submit additional information to the assigned IRO within: 5 business days The assigned IRO shall then select one or more clinical reviewers within: one business day The Plan shall provide to the assigned IRO the documents and any information used in making the Adverse Determination or Final Adverse Determination within: 5 business days of notice of assigned IRO After being selected by the assigned IRO, each clinical reviewer shall provide an opinion to the assigned IRO on whether the recommended or request health care service shall be covered within: 20 days Experimental or Investigational Treatment External Review Timing or, in the case of an expedited external review: immediately, but in no event more than 5 calendar days The assigned IRO shall make a decision after receipt of the opinion from each clinical reviewer and provide notification of the decision to the DirectorIDOI, you or your authorized representative and the Plan within: 20 days or, in the case of an expedited external review, within: 48 hours after receipt of the opinion of each clinical reviewer OTHER THINGS YOU SHOULD KNOW REIMBURSEMENT PROVISION If you or one of your covered dependents incur expenses for sickness or injury that occurred due to the negligence of a third party and benefits have been pro­ vided provided for Covered Services described in this Policy, you agree:

Adverse Determination. The IRO shall provide notice of its decision to uphold or reverse the Adverse Determination or Final Adverse Determination to the Plan, the Director and you: as expeditiously as your medical condition or circumstances require, but no more than 72 hours after the receipt of request. External Review of Experimental or Investigational Treatment Experimental or Investigational Treatment External Review Timing You may file a request with the Director for an external review after receipt of an Adverse Determination or a Final Adverse Determination within: 4 months after date of receipt If your treating Physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, you may make an oral request for an expedited external review, after which the Director shall immediately notify the Plan and the time frames otherwise applicable to Expedited External Review shall apply. After the receipt for an external review, the Director shall send a copy of the request to the Plan within: one business day The Plan shall complete a preliminary review of the request within: 5 business days GB‐16 HCSC 93 Experimental or Investigational Treatment External Review Timing After completion of the preliminary review, the Plan shall notify you and the Director whether the request is complete and eligible for external review within: one business day When the Director receives notice that the request is eligible for external review, the Director shall: assign an IRO and notify the Plan of the name of the IRO, within: one business day notify you of the request's eligibility and acceptance for external review and the name of the IRO, within: one business day If you are notified that your request for an external review has been accepted, you must submit additional information to the assigned IRO within: 5 business days The assigned IRO shall then select one or more clinical reviewers within: one business day The Plan shall provide to the assigned IRO the documents and any information used in making the Adverse Determination or Final Adverse Determination within: 5 business days of notice of assigned IRO After being selected by the assigned IRO, each clinical reviewer shall provide an opinion to the assigned IRO on whether the recommended or request health care service shall be covered within: 20 days Experimental or Investigational Treatment External Review Timing or, in the case of an expedited external review: immediately, but in no event more than 5 calendar days The assigned IRO shall make a decision after receipt of the opinion from each clinical reviewer and provide notification of the decision to the Director, you and the Plan within: 20 days or, in the case of an expedited external review, within: 48 hours after receipt of the opinion of each clinical reviewer OTHER THINGS YOU SHOULD KNOW REIMBURSEMENT PROVISION If you or one of your covered dependents incur expenses for sickness or injury that occurred due to the negligence of a third party and benefits have been pro­ vided for Covered Services described in this Policy, you agree:GB‐16 HCSC 94