Common use of Appeals of Adverse Benefit Determinations Clause in Contracts

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. 24 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. 24 hours Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels one level of Appeal of the adverse benefit determination. The Member must complete the two levels that level of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second levelAppeal, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. 72 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 14 calendar daysdays from receipt of the appeal. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. hours Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. days Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member However, Level One Appeals may also choose to have another person (an authorized representative) make the Appeal be requested orally. A Member, or a Provider acting on behalf of a Member and with the Member’s behalf by providing consent, dissatisfied with a utilization management adverse benefit determination will have the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the opportunity to Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before pursuing an Appeal to an independent utilization review organization (IURO) or bringing a lawsuit against the HMO, unless serious or significant harm to the Member has occurred or will imminently occur. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how HMO’s notice at the Appeals are handled for different types conclusion of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim the Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint explaining the Member’s right to make a Level Two Appeal. Within 10 business days of receipt of a Level Two Appeal, the HMO will acknowledge the Appeal or Complaint Review HMO Response Time from Receipt of in writing. The Level One Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize review will be conducted by a Physician who was not the life or health original reviewer nor a subordinate of the Member, original reviewer who rendered the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. Review provided by HMO personnel not involved in making the initial adverse benefit determination. Within 36 hours. Review provided For a Level Two Appeal, the HMO will conduct a same or similar specialty review for Appeals involving clinical issues before a panel of Physicians and/or other health care professionals selected by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval who have not been involved in any of the benefit in advance of obtaining medical care. Within 15 calendar days. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. Review provided by HMO Appeals Committeeprevious utilization management decisions.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two levels level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the two levels of HMO review Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will provide an option to request an Appeal to Independent Review Agency. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. 24 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. 24 hours Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. days Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two levels level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the two levels of HMO review Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice may provide an option to request an External Review (if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. -36 hours Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. days Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two levels level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the two levels of HMO review Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice may provide an option to request an External Review (if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. -36 hours Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. days Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for one; two levels level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the two levels of HMO review Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice may provide an option to request an External Review (if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. hours Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. days Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. days Review provided by HMO Appeals Committeepersonnel not involved in making the adverse benefit determination or Level One Appeal decision.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing or by calling Member Services (see your identification card) within 365 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two levels level(s) of Appeal of the adverse benefit determination. The Member must complete all steps in the two levels of HMO review Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice may provide an option to request an External Review (if available). If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hourshours Review provided by HMO personnel not involved in making the adverse benefit determination Within -36 hours Review provided by HMO Appeals Committee. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. Review provided by HMO Appeals Committeedetermination or Level One Appeal decision. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar daysdays Review provided by HMO personnel not involved in making the adverse benefit determination.. Within 15 calendar days Review provided by HMO Appeals Committee. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. Review provided by HMO Appeals Committeedetermination or Level One Appeal decision.