Common use of An Appeal Clause in Contracts

An Appeal. You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to us by calling the toll-free number on your ID card. Appeals of adverse benefit determinations You can appeal our adverse benefit determination. We will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. You can appeal by sending a written appeal to the address on the notice of adverse benefit determination, by calling the toll-free number on your ID card. You need to include: • Your name • Your employer’s name • A copy of the adverse benefit determination • Your reasons for making the appeal • Any other information you would like us to consider Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by calling the toll-free number on your ID card. You can use an authorized representative at any level of appeal. You can appeal two times under this plan. If you appeal a second time you must present your appeal within 60 calendar days from the date you receive the notice of the first appeal decision. Urgent care or pre-service claim appeals If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having to fill out a form. We will provide you with any new or additional information that we used or that was developed by us to review your claim. We will provide this information at no cost to you before we give you a decision at your last available level of appeal. This decision is called the final adverse benefit determination. You can respond to this information before we tell you what our final decision is. Timeframes for deciding appeals The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision. Type of notice Urgent care claim Pre-service claim Post-service claim Concurrent care claim Appeal determinations at each level (us) 36 hours 15 days 30 days As appropriate to type of claim Extensions None None None Exhaustion of appeals process In most situations you must complete the two levels of appeal with us before you can take these other actions: • Contact the California Department of Managed Health Care to request an investigation of a complaint or appeal. File a complaint or appeal with the California Department of Managed Health Care. • Appeal through an external review process. • Pursue arbitration, litigation or other type of administrative proceeding. But sometimes you do not have to complete the two levels of appeals process before you may take other actions. These situations are: • You have an urgent claim or a claim that involves ongoing treatment. You can have your claim reviewed internally and at the same time through the independent medical review process. • We did not follow all of the claim determination and appeal requirements of the Federal Department of Health and Human Services. But, you will not be able to proceed directly to external review if: - The rule violation was minor and not likely to influence a decision or harm you. - The violation was for a good cause or beyond our control. - The violation was part of an ongoing, good faith exchange between you and us. Independent medical review Independent medical review is a review managed by the California Department of Managed Health Care. You have a right to an independent medical review if: • We decided the service or supply is not medically necessary or not appropriate (disputed health care service). • We decided the service or supply is experimental or investigational. If our claim decision is one for which you can seek independent medical review, we will say that in the notice of adverse benefit determination or final adverse benefit determination we send you. That notice also will include the independent medical review application form. You should complete the form and send it (in the envelope provided) to the California Department of Managed Health Care. The Department will review your request and determine if you are eligible for independent medical review. When we receive notice from the Department approving your request for an independent medical review, we will submit the documents required to the Department, you and your provider. Your appeal will be submitted to the Independent Medical Review Organization (IMRO) for review by a medical specialist or a panel of medical specialists. Those specialists will determine whether or not the care is medically necessary. You will receive a copy of the independent medical review assessment. The independent medical review will not cost you any money. Independent medical review procedure for disputed health care services You must: • File an appeal regarding the disputed health care services • Have participated in our appeals process for 30 days • Received our final appeal decision If your appeal involves an expedited complaint or appeal, you are not required to participate in our appeals process for more than three days. Your provider must have recommended the services or you must have received urgent or emergency care that a provider deemed medically necessary. Or, you must have been seen by a provider for the diagnosis or treatment of the medical condition. Upon request, we will expedite access to a network provider. You may request an independent medical review whether or not the provider recommends the service. You may also request an independent medical review for services recommended or performed by an out-of-network provider. We have no liability to pay for the services of an out-of-network provider unless you have been referred according to the referral requirements. See the Medical necessity, referral and precertification requirements section for more details. Independent medical review procedure for experimental and investigative treatment You can request an independent medical review when: • You have a life-threatening or seriously debilitating illness • Your physician certifies that you have that condition and: - Standard therapies have not been effective in improving your condition - Standard therapies would not be medically appropriate - There is no more beneficial standard therapy covered by the plan than what your physician is proposing - Your physician has certified in writing that the proposed treatment is more beneficial to you than any other standard therapy - You or your physician has provided us with a written statement that certifies the requested treatment is more beneficial to you than any other standard therapy. You or your physician must base this statement on two forms of medical and scientific evidence. The chart below shows a timetable view of the independent medical review timeline. Type of treatment When we notify you When we send info to the DMHC When the IMRO decides Experimental and investigative 5 days 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request Disputed healthcare services At the end of the appeals process 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request What happens after the IMRO makes their decision? If the IMRO determines that the care requested is medically necessary, or does not qualify as experimental or investigational, we will cover the services which were the subject of the appeal. There are two scenarios when you may be able to get a faster external review: For initial adverse determinations Your provider tells us that a delay in your receiving health care services would: • Jeopardize your life, health or ability to regain maximum function, or • Be much less effective if not started right away (in the case of experimental or investigational treatment) For final adverse determinations Your provider tells us that a delay in your receiving health care services would: • Jeopardize your life, health or ability to regain maximum function • Be much less effective if not started right away (in the case of experimental or investigational treatment), or • The final adverse determination concerns an admission, availability of care, continued stay or health care service for which you received emergency services, but have not been discharged from a facility If your situation qualifies for this faster review, you will receive a decision within 72 hours of us getting your request.

An Appeal. You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to us by calling the toll-free number verbally or in writing. Claim decisions and appeal procedures Your provider may contact us at various times to make a claim, or to request approval for payment based on your ID cardbenefits. This can be before you receive your benefit, while you are receiving benefits and after you have received the benefit. You may not agree with our decision. As we said in Benefit payments and claims in the How your plan works section, we pay many claims at the full rate, except for your share of the costs. But sometimes we pay only some of the claim. Sometimes we deny payment entirely. Any time we deny even part of the claim, it is an “adverse benefit determination” or “adverse decision.” For any adverse decision, you will receive an explanation of benefits in writing. You can ask us to review an adverse benefit determination. This is the internal appeal process. If you still don’t agree, you can also appeal that decision. There are times you may skip the two levels of internal appeal. But in most situations, you must complete both levels before you can take any other actions, such as an external review. Appeals of adverse benefit determinations You can appeal our adverse benefit determination. We will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. Aetna will handle all first level appeals. You can appeal by sending a written appeal to Member Services at the address on the notice of adverse benefit determination, by calling . Or you can call Member Services at the toll-free number on your ID card. You need to include: • Your name • Your The employer’s name • A copy of the adverse benefit determination • Your reasons for making the appeal • Any other information you would like us to consider Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by calling the toll-free number on your ID cardcontacting us. You can use an authorized representative at any level of appeal. You can appeal two times under this plan. If you appeal a second time you The plan sponsor will handle all other level of appeals after the first level. Second level appeals must present your appeal be presented within 60 calendar days from the date you receive the notice of the first appeal decision. Aetna will notify you in our first level appeal decision that your appeal is eligible for a second level appeal with your employer. Urgent care or pre-service claim appeals If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having to you fill out a forman authorized representative form telling us that you are allowing the provider to appeal for you. We will provide you with any new or additional information that we used or that was developed by us to review your claim. We will provide this information at no cost to you before we give you a decision at your last available level of appeal. This decision is called the final adverse benefit determination. You can respond to this information before we tell you what our final decision is. Timeframes for deciding appeals The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision. Type of notice Urgent care claim Pre-service claim Post-service claim Concurrent care claim Appeal determinations at each level (us) 36 hours 15 days 30 days As appropriate to type of claim Extensions None None None Exhaustion of appeals process In most situations you must complete the two levels of appeal with us before you can take these other actions: • Contact the California Department of Managed Health Care to request an investigation of a complaint or appeal. File a complaint or appeal with the California Department of Managed Health Care. • Appeal through an external review process. • Pursue arbitration, litigation or other type of administrative proceeding. But sometimes you do not have to complete the two levels of appeals process before you may take other actions. These situations are: • You have an urgent claim or a claim that involves ongoing treatment. You can have your claim reviewed internally and at the same time through the independent medical external review process. • We did not follow all of the claim determination and appeal requirements of the Federal Department of Health and Human Services. But, you will not be able to proceed directly to external review if: - The rule violation was minor and not likely to influence a decision or harm you. - The violation was for a good cause or beyond our control. - The violation was part of an ongoing, good faith exchange between you and us. Independent medical review Independent medical review is a review managed by the California Department of Managed Health Care. You have a right to an independent medical review if: • We decided the service or supply is not medically necessary or not appropriate (disputed health care service). • We decided the service or supply is experimental or investigational. If our claim decision is one for which you can seek independent medical review, we will say that in the notice of adverse benefit determination or final adverse benefit determination we send you. That notice also will include the independent medical review application form. You should complete the form and send it (in the envelope provided) to the California Department of Managed Health Care. The Department will review your request and determine if you are eligible for independent medical review. When we receive notice from the Department approving your request for an independent medical review, we will submit the documents required to the Department, you and your provider. Your appeal will be submitted to the Independent Medical Review Organization (IMRO) for review by a medical specialist or a panel of medical specialists. Those specialists will determine whether or not the care is medically necessary. You will receive a copy of the independent medical review assessment. The independent medical review will not cost you any money. Independent medical review procedure for disputed health care services You must: • File an appeal regarding the disputed health care services • Have participated in our appeals process for 30 days • Received our final appeal decision If your appeal involves an expedited complaint or appeal, you are not required to participate in our appeals process for more than three days. Your provider must have recommended the services or you must have received urgent or emergency care that a provider deemed medically necessary. Or, you must have been seen by a provider for the diagnosis or treatment of the medical condition. Upon request, we will expedite access to a network provider. You may request an independent medical review whether or not the provider recommends the service. You may also request an independent medical review for services recommended or performed by an out-of-network provider. We have no liability to pay for the services of an out-of-network provider unless you have been referred according to the referral requirements. See the Medical necessity, referral and precertification requirements section for more details. Independent medical review procedure for experimental and investigative treatment You can request an independent medical review when: • You have a life-threatening or seriously debilitating illness • Your physician certifies that you have that condition and: - Standard therapies have not been effective in improving your condition - Standard therapies would not be medically appropriate - There is no more beneficial standard therapy covered by the plan than what your physician is proposing - Your physician has certified in writing that the proposed treatment is more beneficial to you than any other standard therapy - You or your physician has provided us with a written statement that certifies the requested treatment is more beneficial to you than any other standard therapy. You or your physician must base this statement on two forms of medical and scientific evidence. The chart below shows a timetable view of the independent medical review timeline. Type of treatment When we notify you When we send info to the DMHC When the IMRO decides Experimental and investigative 5 days 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request Disputed healthcare services At the end of the appeals process 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request What happens after the IMRO makes their decision? If the IMRO determines that the care requested is medically necessary, or does not qualify as experimental or investigational, we will cover the services which were the subject of the appeal. There are two scenarios when you may be able to get a faster external review: For initial adverse determinations Your provider tells us that a delay in your receiving health care services would: • Jeopardize your life, health or ability to regain maximum function, or • Be much less effective if not started right away (in the case of experimental or investigational treatment) For final adverse determinations Your provider tells us that a delay in your receiving health care services would: • Jeopardize your life, health or ability to regain maximum function • Be much less effective if not started right away (in the case of experimental or investigational treatment), or • The final adverse determination concerns an admission, availability of care, continued stay or health care service for which you received emergency services, but have not been discharged from a facility If your situation qualifies for this faster review, you will receive a decision within 72 hours of us getting your request.

An Appeal. You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to us by calling the toll-free number on your ID card. Appeals of adverse benefit determinations You can appeal our adverse benefit determination. We will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. You can appeal by sending a written appeal to the address on the notice of adverse benefit determination, by calling the toll-free number on your ID card. You need to include: •  Your name •  Your employer’s name •  A copy of the adverse benefit determination •  Your reasons for making the appeal •  Any other information you would like us to consider Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by calling the toll-free number on your ID card. You can use an authorized representative at any level of appeal. You can appeal two times under this plan. If you appeal a second time you must present your appeal within 60 calendar days from the date you receive the notice of the first appeal decision. Urgent care or pre-service claim appeals If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having to fill out a form. We will provide you with any new or additional information that we used or that was developed by us to review your claim. We will provide this information at no cost to you before we give you a decision at your last available level of appeal. This decision is called the final adverse benefit determination. You can respond to this information before we tell you what our final decision is. Timeframes for deciding appeals The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision. Type of notice Urgent care claim Pre-service claim Post-service claim Concurrent care claim Appeal determinations at each level (us) 36 hours 15 days 30 days As appropriate to type of claim Extensions None None None Exhaustion of appeals process In most situations you must complete the two levels of appeal with us before you can take these other actions: •  Contact the California Department of Managed Health Care to request an investigation of a complaint or appeal. File a complaint or appeal with the California Department of Managed Health Care. •  Appeal through an external review process. •  Pursue arbitration, litigation or other type of administrative proceeding. But sometimes you do not have to complete the two levels of appeals process before you may take other actions. These situations are: •  You have an urgent claim or a claim that involves ongoing treatment. You can have your claim reviewed internally and at the same time through the independent medical review process. •  We did not follow all of the claim determination and appeal requirements of the Federal Department of Health and Human Services. But, you will not be able to proceed directly to external review if: - The rule violation was minor and not likely to influence a decision or harm you. - The violation was for a good cause or beyond our control. - The violation was part of an ongoing, good faith exchange between you and us. Independent medical review Independent medical review is a review managed by the California Department of Managed Health Care. You have a right to an independent medical review if: •  We decided the service or supply is not medically necessary or not appropriate (disputed health care service). •  We decided the service or supply is experimental or investigational. If our claim decision is one for which you can seek independent medical review, we will say that in the notice of adverse benefit determination or final adverse benefit determination we send you. That notice also will include the independent medical review application form. You should complete the form and send it (in the envelope provided) to the California Department of Managed Health Care. The Department will review your request and determine if you are eligible for independent medical review. When we receive notice from the Department approving your request for an independent medical review, we will submit the documents required to the Department, you and your provider. Your appeal will be submitted to the Independent Medical Review Organization (IMRO) for review by a medical specialist or a panel of medical specialists. Those specialists will determine whether or not the care is medically necessary. You will receive a copy of the independent medical review assessment. The independent medical review will not cost you any money. Independent medical review procedure for disputed health care services You must: •  File an appeal regarding the disputed health care services •  Have participated in our appeals process for 30 days •  Received our final appeal decision If your appeal involves an expedited complaint or appeal, you are not required to participate in our appeals process for more than three days. Your provider must have recommended the services or you must have received urgent or emergency care that a provider deemed medically necessary. Or, you must have been seen by a provider for the diagnosis or treatment of the medical condition. Upon request, we will expedite access to a network provider. You may request an independent medical review whether or not the provider recommends the service. You may also request an independent medical review for services recommended or performed by an out-of-network provider. We have no liability to pay for the services of an out-of-network provider unless you have been referred according to the referral requirements. See the Medical necessity, referral and precertification requirements section for more details. Independent medical review procedure for experimental and investigative treatment You can request an independent medical review when: •  You have a life-threatening or seriously debilitating illness •  Your physician certifies that you have that condition and: - Standard therapies have not been effective in improving your condition - Standard therapies would not be medically appropriate - There is no more beneficial standard therapy covered by the plan than what your physician is proposing - Your physician has certified in writing that the proposed treatment is more beneficial to you than any other standard therapy - You or your physician has provided us with a written statement that certifies the requested treatment is more beneficial to you than any other standard therapy. You or your physician must base this statement on two forms of medical and scientific evidence. The chart below shows a timetable view of the independent medical review timeline. Type of treatment When we notify you When we send info to the DMHC When the IMRO decides Experimental and investigative 5 days 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request Disputed healthcare services At the end of the appeals process 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request What happens after the IMRO makes their decision? If the IMRO determines that the care requested is medically necessary, or does not qualify as experimental or investigational, we will cover the services which were the subject of the appeal. There are two scenarios when you may be able to get a faster external review: For initial adverse determinations Your provider tells us that a delay in your receiving health care services would: •  Jeopardize your life, health or ability to regain maximum function, or •  Be much less effective if not started right away (in the case of experimental or investigational treatment) For final adverse determinations Your provider tells us that a delay in your receiving health care services would: •  Jeopardize your life, health or ability to regain maximum function •  Be much less effective if not started right away (in the case of experimental or investigational treatment), or •  The final adverse determination concerns an admission, availability of care, continued stay or health care service for which you received emergency services, but have not been discharged from a facility If your situation qualifies for this faster review, you will receive a decision within 72 hours of us getting your request.

An Appeal. You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to us by calling the toll-free number verbally or in writing. Claim decisions and appeal procedures Your provider may contact us at various times to make a claim, or to request approval for payment based on your ID cardbenefits. This can be before you receive your benefit, while you are receiving benefits and after you have received the benefit. You may not agree with our decision. As we said in Benefit payments and claims in the How your plan works section, we pay many claims at the full rate, except for your share of the costs. But sometimes we pay only some of the claim. Sometimes we deny payment entirely. Any time we deny even part of the claim, it is an “adverse benefit determination” or “adverse decision.” For any adverse decision, you will receive an explanation of benefits in writing. You can ask us to review an adverse benefit determination. This is the internal appeal process. If you still don’t agree, you can also appeal that decision. There are times you may skip the two levels of internal appeal. But in most situations, you must complete both levels before you can take any other actions, such as an external review. Appeals of adverse benefit determinations You can appeal our adverse benefit determination. We will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. You can appeal by sending a written appeal to Member Services at the address on the notice of adverse benefit determination, by calling . Or you can call Member Services at the toll-free number on your ID card. You need to include: • Your name • Your The employer’s name • A copy of the adverse benefit determination • Your reasons for making the appeal • Any other information you would like us to consider Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by calling the toll-free number on your ID cardcontacting us. You can use an authorized representative at any level of appeal. You can appeal two times under this plan. If you appeal a second time you must present your appeal within 60 calendar days from the date you receive the notice of the first appeal decision. Urgent care or pre-service claim appeals If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having to you fill out a forman authorized representative form telling us that you are allowing the provider to appeal for you. We will provide you with any new or additional information that we used or that was developed by us to review your claim. We will provide this information at no cost to you before we give you a decision at your last available level of appeal. This decision is called the final adverse benefit determination. You can respond to this information before we tell you what our final decision is. Timeframes for deciding appeals The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision. Type of notice Urgent care claim Pre-service claim Post-service claim Concurrent care claim Appeal determinations at each level (us) 36 hours 15 days 30 days As appropriate to type of claim Extensions None None None Exhaustion of appeals process In most situations you must complete the two levels of appeal with us before you can take these other actions: • Contact the California Department of Managed Health Care to request an investigation of a complaint or appeal. File a complaint or appeal with the California Department of Managed Health Care. • Appeal through an external review process. • Pursue arbitration, litigation or other type of administrative proceeding. But sometimes you do not have to complete the two levels of appeals process before you may take other actions. These situations are: • You have an urgent claim or a claim that involves ongoing treatment. You can have your claim reviewed internally and at the same time through the independent medical external review process. • We did not follow all of the claim determination and appeal requirements of the Federal Department of Health and Human Services. But, you will not be able to proceed directly to external review if: - The rule violation was minor and not likely to influence a decision or harm you. - The violation was for a good cause or beyond our control. - The violation was part of an ongoing, good faith exchange between you and us. Independent medical External review Independent medical External review is a review managed done by the California Department people in an organization outside of Managed Health CareAetna. This is called an external review organization (ERO). You have a right to an independent medical external review only if: • Our claim decision involved medical judgment. • We decided the service or supply is not medically necessary or not appropriate (disputed health care service)appropriate. • We decided the service or supply is experimental or investigational. • You have received an adverse determination. You may also request external review if you want to know if the federal surprise xxxx xxx applies to your situation. If our claim decision is one for which you can seek independent medical external review, we will say that in the notice of adverse benefit determination or final adverse benefit determination we send you. That notice also will describe the external review process. It will include the independent medical review application form. You should complete the form and send it (in the envelope provided) to the California Department of Managed Health Care. The Department will review your request and determine if you are eligible for independent medical review. When we receive notice from the Department approving your request for an independent medical review, we will submit the documents required to the Department, you and your provider. Your appeal will be submitted to the Independent Medical Review Organization (IMRO) for review by a medical specialist or a panel of medical specialists. Those specialists will determine whether or not the care is medically necessary. You will receive a copy of the independent medical review assessmentRequest for External Review form at the final adverse determination level. The independent medical review will not cost you any money. Independent medical review procedure You must submit the Request for disputed health care services You mustExternal Review Form: • File To Aetna • Within 123 calendar days (four months) of the date you received the decision from us • And you must include a copy of the notice from us and all other important information that supports your request You will pay for any information that you send and want reviewed by the ERO. We will pay for information we send to the ERO plus the cost of the review. Aetna will: • Contact the ERO that will conduct the review of your claim. • Assign the appeal to one or more independent clinical reviewers that have the proper expertise to do the review. • Consider appropriate credible information that you sent. • Follow our contractual documents and your plan of benefits. • Send notification of the decision within 45 calendar days of the date we receive your request form and all the necessary information. We will stand by the decision that the ERO makes, unless we can show conflict of interest, bias or fraud. How long will it take to get an appeal regarding ERO decision? We will tell you of the disputed health care services • Have participated in our appeals process for 30 days • Received our final appeal ERO decision If your appeal involves an expedited complaint or appeal, you are not required to participate in our appeals process for more than three days45 calendar days after we receive your Notice of External Review Form with all the information you need to send in. But sometimes you can get a faster external review decision. Your provider must have recommended the services call us or you must have received urgent or emergency care that send us a provider deemed medically necessary. Or, you must have been seen by a provider Request for the diagnosis or treatment of the medical condition. Upon request, we will expedite access to a network provider. You may request an independent medical review whether or not the provider recommends the service. You may also request an independent medical review for services recommended or performed by an out-of-network provider. We have no liability to pay for the services of an out-of-network provider unless you have been referred according to the referral requirements. See the Medical necessity, referral and precertification requirements section for more details. Independent medical review procedure for experimental and investigative treatment You can request an independent medical review when: • You have a life-threatening or seriously debilitating illness • Your physician certifies that you have that condition and: - Standard therapies have not been effective in improving your condition - Standard therapies would not be medically appropriate - There is no more beneficial standard therapy covered by the plan than what your physician is proposing - Your physician has certified in writing that the proposed treatment is more beneficial to you than any other standard therapy - You or your physician has provided us with a written statement that certifies the requested treatment is more beneficial to you than any other standard therapy. You or your physician must base this statement on two forms of medical and scientific evidence. The chart below shows a timetable view of the independent medical review timeline. Type of treatment When we notify you When we send info to the DMHC When the IMRO decides Experimental and investigative 5 days 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request Disputed healthcare services At the end of the appeals process 3 days after receiving notice they approved your request 24 hours for urgent request 30 days 3 days for urgent request What happens after the IMRO makes their decision? If the IMRO determines that the care requested is medically necessary, or does not qualify as experimental or investigational, we will cover the services which were the subject of the appealExternal Review Form. There are two scenarios when you may be able to get a faster external review: For initial adverse determinations Your provider tells us that a delay in your receiving health care services would: • Jeopardize your life, health or ability to regain maximum function, or • Be much less effective if not started right away (in the case of experimental or investigational treatment) For final adverse determinations Your provider tells us that a delay in your receiving health care services would: • Jeopardize your life, health or ability to regain maximum function • Be much less effective if not started right away (in the case of experimental or investigational treatment), or • The final adverse determination concerns an admission, availability of care, continued stay or health care service for which you received emergency services, but have not been discharged from a facility If your situation qualifies for this faster review, you will receive a decision within 72 hours of us getting your request.