Common use of Assignment of IRO Clause in Contracts

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director shall immediately assign an IRO on a random basis from the list of IROs approved by the Director; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information in writing to the assigned IRO. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ termination. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cable, your authorized representative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director shall immediately assign an IRO on a random basis from the list of IROs approved by the Director; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information in writing to the assigned IRO. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ termination. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cable, your authorized representative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO

Assignment of IRO. If When the IDOI receives notice that your request is eligible for expedited external re­ viewreview following the preliminary review, the Director shall immediately IDOI will, within one business day after the receipt of the notice, a) assign an IRO on a random basis from the list of those IROs approved by the DirectorIDOI; and immediately (b) notify the Plan Plan, you and your authorized representative, if applicable, of the request's eligibility and acceptance for external review and the name of the IRO. Upon Within five business days after the date of receipt from the Director of the name notice provided by the IDOI of the IRO assigned to conduct the external reviewassignment of an IRO, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information may, within five business days following the date of receipt of the notice of assignment of an IRO, submit in writing to the assigned IROIRO additional informa­ tion that the IRO shall consider when conducting the external review. The IRO is not required to, but may, accept and consider additional in­ formation submitted after five business days. If the Plan or its designated utilization review organization does not provide the docu­ ments and information within five business days, the IRO may end the external review and make a decision to reverse the Adverse Determin­ ation or Final Adverse Determination. A failure by the Plan or designated utilization review organization to provide the documents and information to the IRO within 24 hoursfive business days shall not delay the conduct of the external review. Within one business day after mak­ ing the decision to end the external review, the IRO shall notify the Plan, you and, if applicable, your authorized representative, of its de­ cision to reverse the determination. If you or your authorized representative submitted additional informa­ tion to the IRO, the IRO shall forward the additional information to the Plan within one business day of receipt from you or your authorized representative. Upon receipt of such information, the Plan may recon­ sider the Adverse Determination or Final Adverse Determination. Such reconsideration shall not delay the external review. The Plan may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. Within one business day after making the decision to end the external review, the IRO Plan shall notify the DirectorIDOI, the PlanIRO, you andyou, and if appli­ cableapplicable, your authorized representative, rep­ resentative of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO.

Assignment of IRO. If your request is eligible for expedited external re­ re- view, the Director shall immediately assign an IRO on a random basis from the list of IROs approved by the Director; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ organiza- tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ informa- tion considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ sub- mit additional information in writing to the assigned IRO. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ De- termination. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ appli- cable, your authorized representative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ De- termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ determina- tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ representat- ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ treat- ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ circum- stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ clinic- al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ dur- ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ Deter- mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ Deter- mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IROIRO If the Plan fails to provide the necessary documents and information within the required time mentioned above, the assigned IRO may terminate the external review and make a decision to reverse the Adverse Determination or Final 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

Assignment of IRO. If When the IDOI receives notice that your request is eligible for expedited external re­ viewreview following the preliminary review, the Director shall immediately IDOI will, within one business day after the receipt of the notice, a) assign an IRO on a random basis from the list of those IROs approved by the DirectorIDOI; and immediately (b) notify the Plan Plan, you and your authorized representative, if applicable, of the request's eligibility and acceptance for external review and the name of the IRO. Upon Within five business days after the date of receipt from the Director of the name notice provided by the IDOI of the IRO assigned to conduct the external reviewassignment of an IRO, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information may, within five business days following the date of receipt of the notice of assignment of an IRO, submit in writing to the assigned IROIRO additional informa­ tion that the IRO shall consider when conducting the external review. The IRO is not required to, but may, accept and consider additional in­ formation submitted after five business days. If the Plan or its designated utilization review organization does not provide the docu­ ments and information within five business days, the IRO may end the external review and make a decision to reverse the Adverse Determin­ ation or Final Adverse Determination. A failure by the Plan or designated utilization review organization to provide the documents and information to the IRO within 24 hoursfive business days shall not delay the conduct of the external review. Within one business day after mak­ ing the decision to end the external review, the IRO shall notify the Plan, you and, if applicable, your authorized representative, of its de­ cision to reverse the determination. If you or your authorized representative submitted additional in­ formation to the IRO, the IRO shall forward the additional information to the Plan within one business day of receipt from you or your authorized representative. Upon receipt of such in­ formation, the Plan may reconsider the Adverse Determination or Final Adverse Determination. Such reconsideration shall not delay the external review. The Plan may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. Within one business day after making the decision to end the external review, the IRO Plan shall notify the DirectorIDOI, the PlanIRO, you andyou, and if appli­ cableapplicable, your authorized representative, representative of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO.

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director shall immediately assign an IRO on a random basis from the list of IROs approved by the Director; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information in writing to the assigned IRO. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ termination. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cable, your authorized representative, of its decision to reverse the determination. GB‐16 HCSC 92 As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IROGB‐16 HCSC 93

Assignment of IRO. If When the IDOI receives notice that your request is eligible for expedited external re­ viewreview following the preliminary review, the Director shall immediately IDOI will, within one business day after the receipt of the notice, a) assign an IRO on a random basis from the list of those IROs approved by the DirectorIDOI; and immediately (b) notify the Plan Plan, you and your authorized representative, if applicable, of the request's eligibility and acceptance for external review and the name of the IRO. Upon Within five business days after the date of receipt from the Director of the name notice provided by the IDOI of the IRO assigned to conduct the external reviewassignment of an IRO, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information may, within five business days following the date of receipt of the notice of assignment of an IRO, submit in writing to the assigned IROIRO additional information that the IRO shall consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted after five business days. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hoursfive business days, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. A failure by the Plan or designated utilization review organization to provide the documents and information to the IRO within five business days shall not delay the conduct of the external review. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cableapplicable, your authorized representative, of its decision to reverse the determination. As expeditiously as If you or your medical condition or circumstances requires (but in no event more than 72 hours after authorized representative submitted additional information to the date IRO, the IRO shall forward the additional information to the Plan within one business day of receipt from you or your authorized representative. Upon receipt of such information, the request for an expedited Plan may reconsider the Adverse Determination or Final Adverse Determination. Such reconsideration shall not delay the external review), . The Plan may end the assigned IRO will render external review and make a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will Determination. Within one business day after making the decision to end the external review, the Plan shall notify the DirectorIDOI, the PlanIRO, you andyou, and if applicable, your authorized representative. If the initial notice regarding representative of its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of reverse the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO.

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director shall immediately assign an IRO on a random basis from the list of IROs approved by the Director; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information in writing to the assigned IRO. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ termination. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cable, your authorized representative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO If the Plan fails to provide the necessary documents and information within the required time mentioned above, the assigned IRO may terminate the external review and make a decision to reverse the Adverse Determination or Final 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 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:

Assignment of IRO. If your request is eligible for expedited external re­ viewreview, the Director IDOI shall immediately assign an IRO on a random basis from the list of IROs approved by the DirectorIDOI; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director IDOI of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion organization shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit submit additional information in writing to the assigned IROIRO within 24 hours or additional information may accompany the request for an expedited independent external review. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. Within one business day after making the decision to end the external review, the IRO shall notify the DirectorIDOI, the Plan, you and, if appli­ cableapplicable, your authorized representative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours or 5 days for expedited Experimental/Investigational treatment after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination Determination and will notify the DirectorIDOI, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the DirectorIDOI, the Plan and, if applicable, your authorized representat­ iverepresentative, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ mentstreatments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances circumstances requires, but in no event less more than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al clinical reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the DirectorIDOI, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the DirectorIDOI, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing during the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination Determination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits Coverage will not only be provided for those services and/or supplies that were the subject of the Adverse Determination or Final Adverse Determination and not for additional services or supplies not covered under beyond the benefit program if scope of the IRO determines that external review. If you disagree with the health care services being appealed were medically appropriatedetermination of the IRO, you may file a Complaint with the Illinois Department of Insurance's Office of Consumer Health Insurance. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination Determination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify the IDOI, you or your authorized representative whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the DirectorIDOI. The Director IDOI may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director IDOI shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director IDOI shall immediately assign an IRO on a random basis from the list of IROs approved by the DirectorIDOI; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director IDOI of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion organization shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse DeterminationDeterm­ ination. In addition, you or your authorized representative may sub­ mit submit additional information in writing to the assigned IROIRO within 24 hours or ad­ ditional information may accompany the request for an expedited independent external review. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. Within one business day after making the decision to end the external review, the IRO shall notify the DirectorIDOI, the Plan, you and, if appli­ cableapplicable, your authorized representativerep­ resentative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours or 5 days for expedited Experimental/Invest­ igational treatment after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination Determina­ tion and will notify the DirectorIDOI, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the DirectorIDOI, the Plan and, if applicable, your authorized representat­ iverepresentative, including includ­ ing all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the DirectorIDOI, the Plan, you and your authorized representativerep­ resentative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the DirectorIDOI, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination De­ termination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits Coverage will not only be provided for those services and/or supplies that were the subject of the Adverse Determination or Final Adverse Determination and not for additional services or supplies not covered under beyond the benefit program if scope of the IRO determines that external review. If you disagree with the health care services being appealed were medically appropriatedetermination of the IRO, you may file a Complaint with the Illinois Department of Insurance's Office of Consumer Health In­ surance. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination De­ termination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify the IDOI, you or your authorized representative whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the DirectorIDOI. The Director IDOI may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director IDOI shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO Expedited External Review Timing If the Plan fails to provide the necessary documents and information within the required time mentioned above, the assigned IRO may terminate the external review and make a decision to reverse the Adverse Determination or Final 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 IDOI and you 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 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 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 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 IDOI whether the request is complete and eligible for external review within: one business day When the IDOI receives notice that the request is eligible for external review, the 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 Experimental or Investigational Treatment External Review Timing 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 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 IDOI, 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 for Covered Services described in this Policy, you agree:

Assignment of IRO. If When the IDOI receives notice that your request is eligible for expedited external re­ viewreview following the preliminary review, the Director shall immediately IDOI will, within one business day after the receipt of the notice, a) assign an IRO on a random basis from the list of those IROs approved by the DirectorIDOI; and immediately (b) notify the Plan Plan, you and your authorized representative, if applicable, of the request's eligibility and acceptance for external review and the name of the IRO. Upon Within five business days after the date of receipt from the Director of the name notice provided by the IDOI of the IRO assigned to conduct the external reviewassignment of an IRO, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information may, within five business days following the date of receipt of the notice of assignment of an IRO, submit in writing to the assigned IROIRO additional information that the IRO shall consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted after five business days. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hoursfive business days, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. A failure by the Plan or designated utilization review organization to provide the documents and information to the IRO within five business days shall not delay the conduct of the external review. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cableapplicable, your authorized representative, of its decision to reverse the determination. As expeditiously as If you or your medical condition or circumstances requires (but in no event more than 72 hours after authorized representative submitted additional informa­ tion to the date IRO, the IRO shall forward the additional information to the Plan within one business day of receipt from you or your authorized representative. Upon receipt of such information, the request for an expedited Plan may recon­ sider the Adverse Determination or Final Adverse Determination. Such reconsideration shall not delay the external review), . The Plan may end the assigned IRO will render external review and make a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will Determination. Within one business day after making the decision to end the external review, the Plan shall notify the DirectorIDOI, the PlanIRO, you andyou, and if applicable, your authorized representative. If the initial notice regarding rep­ resentative of its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of reverse the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IRO.

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director IDOI shall immediately assign an IRO on a random basis from the list of IROs approved by the DirectorIDOI; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director IDOI of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion organization shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion information considered in making the Adverse Determination or Final Adverse DeterminationDeterm­ ination. In addition, you or your authorized representative may sub­ mit submit additional information in writing to the assigned IROIRO within 24 hours or ad­ ditional information may accompany the request for an expedited independent external review. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ terminationDetermination. Within one business day after making the decision to end the external review, the IRO shall notify the DirectorIDOI, the Plan, you and, if appli­ cableapplicable, your authorized representativerep­ resentative, of its decision to reverse the determination. As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours or 5 days for expedited Experimental/Invest­ igational treatment after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination Determina­ tion and will notify the DirectorIDOI, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the DirectorIDOI, the Plan and, if applicable, your authorized representat­ iverepresentative, including includ­ ing all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less more than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the DirectorIDOI, the Plan, you and your authorized representativerep­ resentative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the DirectorIDOI, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination De­ termination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits Coverage will not only be provided for those services and/or supplies that were the subject of the Adverse Determination or Final Adverse Determination and not for additional services or supplies not covered under beyond the benefit program if scope of the IRO determines that external review. If you disagree with the health care services being appealed were medically appropriatedetermination of the IRO, you may file a Complaint with the Illinois Department of Insurance's Office of Consumer Health In­ surance. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination De­ termination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify the IDOI, you or your authorized representative whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the DirectorIDOI. The Director IDOI may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director IDOI shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IROIRO Expedited External Review Timing

Assignment of IRO. If your request is eligible for expedited external re­ view, the Director shall immediately assign an IRO on a random basis from the list of IROs approved by the Director; and immediately notify the Plan of the name of the IRO. Upon receipt from the Director of the name of the IRO assigned to conduct the external review, the Plan or its designated utilization review organiza­ tion shall immediately, (but in no case more than 24 hours after receiving such notice) provide to the assigned IRO the documents and any informa­ tion considered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may sub­ mit additional information in writing to the assigned IRO. If the Plan or its designated utilization review organization does not provide the documents and information within 24 hours, the IRO may end the external review and make a decision to reverse the Adverse Determination or Final Adverse De­ termination. Within one business day after making the decision to end the external review, the IRO shall notify the Director, the Plan, you and, if appli­ cable, your authorized representative, of its decision to reverse the determination. GB‐16 HCSC 91 As expeditiously as your medical condition or circumstances requires (but in no event more than 72 hours after the date of receipt of the request for an expedited external review), the assigned IRO will render a decision whether or not to uphold or reverse the Adverse Determination or Final Adverse De­ termination and will notify the Director, the Plan, you and, if applicable, your authorized representative. If the initial notice regarding its determina­ tion was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representat­ ive, including all the information outlined under the standard process above. If the external review was a review of experimental or investigational treat­ ments, each clinical reviewer shall provide an opinion orally or in writing to the assigned IRO as expeditiously as your medical condition or circum­ stances requires, but in no event less than five calendar days after being selected. Within 48 hours after the date it receives the opinion of each clinic­ al reviewer, the IRO will make a decision and provide notice of the decision either orally or in writing to the Director, the Plan, you and your authorized representative, if applicable. If the IRO's initial notice regarding its determination was not in writing, within 48 hours after the date of providing such notice, the assigned IRO shall provide written confirmation of the decision to you, the Director, the Plan and, if applicable, your authorized representative. The assigned IRO is not bound by any decisions or conclusions reached dur­ ing the Plan's utilization review process or the Plan's internal appeal process. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Benefits will not be provided for services or supplies not covered under the benefit program if the IRO determines that the health care services being appealed were medically appropriate. An external review decision is binding on the Plan. An external review decision is binding on you, except to the extent you have other remedies available under applicable federal or state law. You and your authorized representative may not file a subsequent request for external review involving the same Adverse Deter­ mination or Final Adverse Determination for which you have already received an external review decision. Expedited External Review Timing You may file a request for an expedited external review after the date of receipt of a notice prior to Final Adverse Determination: immediately You may file a request for an expedited external review if the Plan fails to provide a decision on a request for an expedited internal appeal within: 48 hours Expedited External Review Timing The Plan must immediately notify you whether the request is complete and eligible for an expedited external review or is ineligible for review and may be appealed to the Director. The Director may make a determination that the request is eligible for an expedited external review, notwithstanding the Plan's determination. The Director shall assign an independent review organization (IRO): immediately The Plan shall provide all necessary documents and information to the IRO: immediately, but not more than 24 hours after assignment of an IROGB‐16 HCSC 92