Common use of Appeal of Adverse Determinations Clause in Contracts

Appeal of Adverse Determinations. An adverse determination is a determination made by HMO or a utilization review agent physician that health care services provided or proposed to be provided are experimental, investigational or not medically necessary. HMO maintains an internal appeal system that provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination. The appeal of an adverse determination process is not part of the complaint process. You, your designated representative or your physician or provider may initiate an appeal of an adverse determination. When services provided or proposed to be provided are deemed experimental, investigational or not medically necessary, HMO or a utilization review agent will regard the expression of dissatisfaction or disagreement as an appeal of an adverse determination. Within five working days of your appeal request, HMO will send you a letter acknowledging the date of receipt of the appeal and a list of documents you must submit. For oral appeals, we will also send you a one-page appeal form for completion that must be returned to HMO. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. We have thirty days from your appeal request to provide you written notice of the appeal determination. You will receive a written decision of the appeal that will include dental, medical and contractual reasons for the resolution; clinical basis for the decision; specialization of provider consulted; notice of your right to have an independent review organization review the denial; and TDI’s toll free telephone number and address. Expedited Appeal of Adverse Determination Procedures Investigation and resolution of appeals relating to ongoing emergencies or denials of continued hospital stays are referred directly to an expedited appeal process and will be concluded in accordance with the medical or dental immediacy of the case. In no event will the request for an expedited appeal exceed one business day from the date all information necessary to complete the appeal request is received or three calendar days of the appeal request, whichever is sooner. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. That physician or provider may interview you and will render a decision on the appeal. The initial notice of the decision may be made orally with written notice of the determination following within three days. Appeals Process to Independent Review Organization An independent review organization is an organization independent of HMO that may perform a final administrative review of an adverse determination made by us. In a circumstance involving a life-threatening or urgent care circumstances or if you do not receive a timely decision, you are entitled to an immediate appeal to an independent review organization rather than going through HMO’s appeal of an adverse determination process. The independent review organization process is not part of the complaint process, but is available only for appeals of adverse determination. You may request a review of an appeal of an adverse determination by the independent review organization. HMO will adhere to the following guidelines/criteria: • Provide you, your designated representative, or your provider of record, information on how to appeal the denial of an adverse determination to an independent review organization; • Provide this information at the initial adverse determination and the denial of the appeal; • Provide the appropriate form to complete; • You, a designated representative, or your provider of record must complete the form and return it to HMO to begin the independent review process; • In life-threatening or urgent care situations, you, your designated representative, or provider of record, may contact HMO by telephone to request the review; • Submit medical records, names of providers and any documentation pertinent to the adverse determination to the independent review organization; • Comply with the determination by the independent review organization; and • Pay for the independent review. Upon request and free of charge you are provided reasonable access to, and copies of all documents, records and other information relevant to the claim or appeal, including: • Information relied upon in making the benefit determination; • Information submitted, considered or generated in the course of making the benefit determination, whether or not it was relied upon in making the benefit determination; • Descriptions of the administrative process and safeguards used in making the benefit determination; • Records of any independent reviews conducted by HMO; • Medical judgments, including determinations about whether a particular service is experimental, investigational, or not medically necessary or appropriate; and • Expert advice and consultation obtained by HMO in connection with the denied claim, whether or not the advice was relied upon in making the benefit determination. The appeal process does not prohibit you from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or relief available under law, if exhausting the procedures of HMO’s process for appeal and review places your health in serious jeopardy.

Appeal of Adverse Determinations. An adverse determination is a determination made by HMO or a utilization review agent physician that health care services provided or proposed to be provided are experimental, investigational or not medically necessary. In life-threatening or urgent care circumstances, if HMO has discontinued coverage of prescription drugs or intravenous infusions for which You were receiving health benefits under the plan, or if you do not receive a timely decision, you are entitled to an immediate appeal to an Independent Review Organization (“IRO”) and are not required to comply with HMO’s appeal of an Adverse Determination process. An IRO is an organization independent of the HMO which may perform a final administrative review of an Adverse Determination made by HMO. Sample HMO maintains an internal appeal system that provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination. The appeal of an adverse determination process is not part of the complaint process. You, your designated representative or your physician or provider may initiate an appeal of an adverse determination. When services provided or proposed to be provided are deemed experimental, investigational or not medically necessary, HMO or a utilization review agent will regard the expression of dissatisfaction or disagreement as an appeal of an adverse determination. Within five working days of your appeal request, HMO will send you a letter acknowledging the date of receipt of the appeal and a list of documents you must submit. For oral appeals, we will also send you a one-page appeal form for completion that must be returned to HMO. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. We have thirty days from your appeal request to provide you written notice of the appeal determination. You will receive a written decision of the appeal that will include dental, medical and contractual reasons for the resolution; clinical basis for the decision; specialization of provider consulted; notice of your right to have an independent review organization review the denial; and TDI’s toll free telephone number and address. The COMPLAINT PROCEDURE: APPEAL OF ADVERSE DETERMINATION; INDEPENDENT REVIEW ORGANIZATION PROCESS; AND NON-RETALIATION section of the Plan Description and Member Handbook is amended by the deleting the Expedited Appeal of Adverse Determination Procedures section in its entirety and replacing it with the following: Expedited Appeal of Adverse Determination Procedures Investigation and resolution of appeals relating to ongoing emergencies or denials of continued hospital stays stays, or the discontinuance by HMO of prescription drugs or intravenous infusions for which you were receiving health benefits under the plan, are referred directly to an expedited appeal process and will be concluded in accordance with the medical or dental immediacy of the case. In no event will the request for an expedited appeal exceed one business day from the date all information necessary to complete the appeal request is received or three calendar days of the appeal request, whichever is sooner. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. That physician or provider may interview you and will render a decision on the appeal. The initial notice of the decision may be made orally with written notice of the determination following within three days. The COMPLAINT PROCEDURE: APPEAL OF ADVERSE DETERMINATION; INDEPENDENT REVIEW ORGANIZATION PROCESS; AND NON-RETALIATION section of the Plan Description and Member Handbook is amended by the deleting the Appeals Process to Independent Review Organization An independent review organization is an organization independent of HMO that may perform a final administrative review of an adverse determination made by us. In a circumstance involving a life-threatening or urgent care circumstances or if you do not receive a timely decision, you are entitled to an immediate appeal to an independent review organization rather than going through HMO’s appeal of an adverse determination process. The independent review organization process is not part of the complaint process, but is available only for appeals of adverse determination. You may request a review of an appeal of an adverse determination by the independent review organization. HMO will adhere to the following guidelines/criteria: • Provide you, your designated representative, or your provider of record, information on how to appeal the denial of an adverse determination to an independent review organization; • Provide this information at the initial adverse determination section in its entirety and the denial of the appeal; • Provide the appropriate form to complete; • You, a designated representative, or your provider of record must complete the form and return replacing it to HMO to begin the independent review process; • In life-threatening or urgent care situations, you, your designated representative, or provider of record, may contact HMO by telephone to request the review; • Submit medical records, names of providers and any documentation pertinent to the adverse determination to the independent review organization; • Comply with the determination by the independent review organization; and • Pay for the independent review. Upon request and free of charge you are provided reasonable access to, and copies of all documents, records and other information relevant to the claim or appeal, including: • Information relied upon in making the benefit determination; • Information submitted, considered or generated in the course of making the benefit determination, whether or not it was relied upon in making the benefit determination; • Descriptions of the administrative process and safeguards used in making the benefit determination; • Records of any independent reviews conducted by HMO; • Medical judgments, including determinations about whether a particular service is experimental, investigational, or not medically necessary or appropriate; and • Expert advice and consultation obtained by HMO in connection with the denied claim, whether or not the advice was relied upon in making the benefit determination. The appeal process does not prohibit you from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or relief available under law, if exhausting the procedures of HMO’s process for appeal and review places your health in serious jeopardy.following:

Appeal of Adverse Determinations. An adverse determination is a determination made by HMO or a utilization review agent physician that health care services provided or proposed to be provided are experimental, investigational or not medically necessary. Sample HMO maintains an internal appeal system that provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination. The appeal of an adverse determination process is not part of the complaint process. You, your designated representative or your physician or provider may initiate an appeal of an adverse determination. When services provided or proposed to be provided are deemed experimental, investigational or not medically necessary, HMO or a utilization review agent will regard the expression of dissatisfaction or disagreement as an appeal of an adverse determination. Within five working days of your appeal request, HMO will send you a letter acknowledging the date of receipt of the appeal and a list of documents you must submit. For oral appeals, we will also send you a one-page appeal form for completion that must be returned to HMO. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. We have thirty days from your appeal request to provide you written notice of the appeal determination. You will receive a written decision of the appeal that will include dental, medical and contractual reasons for the resolution; clinical basis for the decision; specialization of provider consulted; notice of your right to have an independent review organization review the denial; and TDI’s toll free telephone number and address. Expedited Appeal of Adverse Determination Procedures Investigation and resolution of appeals relating to ongoing emergencies or denials of continued hospital stays are referred directly to an expedited appeal process and will be concluded in accordance with the medical or dental immediacy of the case. In no event will the request for an expedited appeal exceed one business day from the date all information necessary to complete the appeal request is received or three calendar days of the appeal request, whichever is sooner. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. That physician or provider may interview you and will render a decision on the appeal. The initial notice of the decision may be made orally with written notice of the determination following within three days. Appeals Process to Independent Review Organization An independent review organization is an organization independent of HMO that may perform a final administrative review of an adverse determination made by us. In a circumstance involving a life-threatening or urgent care circumstances or if you do not receive a timely decision, you are entitled to an immediate appeal to an independent review organization rather than going through HMO’s appeal of an adverse determination process. The independent review organization process is not part of the complaint process, but is available only for appeals of adverse determination. You may request a review of an appeal of an adverse determination by the independent review organization. HMO will adhere to the following guidelines/criteria: •  Provide you, your designated representative, or your provider of record, information on how to appeal the denial of an adverse determination to an independent review organization; •  Provide this information at the initial adverse determination and the denial of the appeal; •  Provide the appropriate form to complete; •  You, a designated representative, or your provider of record must complete the form and return it to HMO to begin the independent review process; •  In life-threatening or urgent care situations, you, your designated representative, or provider of record, may contact HMO by telephone to request the review; • Sample  Submit medical records, names of providers and any documentation pertinent to the adverse determination to the independent review organization; •  Comply with the determination by the independent review organization; and •  Pay for the independent review. Upon request and free of charge you are provided reasonable access to, and copies of all documents, records and other information relevant to the claim or appeal, including: •  Information relied upon in making the benefit determination; •  Information submitted, considered or generated in the course of making the benefit determination, whether or not it was relied upon in making the benefit determination; •  Descriptions of the administrative process and safeguards used in making the benefit determination; •  Records of any independent reviews conducted by HMO; •  Medical judgments, including determinations about whether a particular service is experimental, investigational, or not medically necessary or appropriate; and •  Expert advice and consultation obtained by HMO in connection with the denied claim, whether or not the advice was relied upon in making the benefit determination. The appeal process does not prohibit you from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or relief available under law, if exhausting the procedures of HMO’s process for appeal and review places your health in serious jeopardy.

Appeal of Adverse Determinations. An adverse determination is a determination made by HMO or a utilization review agent physician that health care services provided or proposed to be provided are experimental, investigational or not medically necessary. HMO maintains an internal appeal system that provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination. The appeal of an adverse determination process is not part of the complaint process. You, your designated representative or your physician or provider may initiate an appeal of an adverse determination. When services provided or proposed to be provided are deemed experimental, investigational or not medically necessary, HMO or a utilization review agent will regard the expression of dissatisfaction or disagreement as an appeal of an adverse determination. Within five working days of your appeal request, HMO will send you a letter acknowledging the date of receipt of the appeal and a list of documents you must submit. For oral appeals, we will also send you a one-page appeal form for completion that must be returned to HMO. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. We have thirty days from your appeal request to provide you written notice of the appeal determination. You will receive a written decision of the appeal that will include dental, medical and contractual reasons for the resolution; clinical basis for the decision; specialization of provider consulted; notice of your right to have an independent review organization review the denial; and TDI’s toll free telephone number and address. Expedited Appeal of Adverse Determination Procedures Investigation and resolution of appeals relating to ongoing emergencies or denials of continued hospital stays are referred directly to an expedited appeal process and will be concluded in accordance with the medical or dental immediacy of the case. In no event will the request for an expedited appeal exceed one business day from the date all information necessary to complete the appeal request is received or three calendar days of the appeal request, whichever is sooner. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. That physician or provider may interview you and will render a decision on the appeal. The initial notice of the decision may be made orally with written notice of the determination following within three days. Appeals Process to Independent Review Organization An independent review organization is an organization independent of HMO that may perform a final administrative review of an adverse determination made by us. In a circumstance involving a life-threatening or urgent care circumstances or if you do not receive a timely decision, you are entitled to an immediate appeal to an independent review organization rather than going through HMO’s appeal of an adverse determination process. The independent review organization process is not part of the complaint process, but is available only for appeals of adverse determination. You may request a review of an appeal of an adverse determination by the independent review organization. HMO will adhere to the following guidelines/criteria: •  Provide you, your designated representative, or your provider of record, information on how to appeal the denial of an adverse determination to an independent review organization; •  Provide this information at the initial adverse determination and the denial of the appeal; •  Provide the appropriate form to complete; •  You, a designated representative, or your provider of record must complete the form and return it to HMO to begin the independent review process; •  In life-threatening or urgent care situations, you, your designated representative, or provider of record, may contact HMO by telephone to request the review; •  Submit medical records, names of providers and any documentation pertinent to the adverse determination to the independent review organization; •  Comply with the determination by the independent review organization; and •  Pay for the independent review. Upon request and free of charge you are provided reasonable access to, and copies of all documents, records and other information relevant to the claim or appeal, including: •  Information relied upon in making the benefit determination; •  Information submitted, considered or generated in the course of making the benefit determination, whether or not it was relied upon in making the benefit determination; •  Descriptions of the administrative process and safeguards used in making the benefit determination; •  Records of any independent reviews conducted by HMO; •  Medical judgments, including determinations about whether a particular service is experimental, investigational, or not medically necessary or appropriate; and •  Expert advice and consultation obtained by HMO in connection with the denied claim, whether or not the advice was relied upon in making the benefit determination. The appeal process does not prohibit you from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or relief available under law, if exhausting the procedures of HMO’s process for appeal and review places your health in serious jeopardy.