Expedited External Review. The Insured or the Insured’s Authorized Representative may request in writing, an internal Expedited Appeal by SHL and an Expedited External Review from OCHA simultaneously if the adverse determination of the requested or recommended service or treatment is determined by SHL to be experimental, investigational or unproven or investigational, and, if the treating provider certifies, in writing, that such service or treatment would be less effective if not promptly initiated. An oral request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of proof from the Insured’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiated. Upon receipt of such request and proof, OCHA shall immediately notify SHL accordingly. SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured or the Insured’s Authorized Representative and OCHA of the determination. If SHL determines the request to be ineligible, the Insured will be notified that the request may be appealed to OCHA. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHL. The IRO has one (1) business day to select one or more clinical reviewers. SHL must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured or Insured’s Authorized Representative may, within five (5) business days after receiving notice of the assigned IRO, submit any additional information in writing to the IRO. Any information submitted by the Insured or the Insured’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured or the Insured’s Authorized Representative must be submitted to SHL by the IRO within one (1) business day. The clinical reviewers have no more than five (5) days to provide an opinion to the IRO. The IRO has forty-eight (48) hours to review the opinion of the clinical reviewers and make a determination. The IRO shall notify the following parties no later than twenty-four (24) hours after completing its External Review: Insured; Insured’s Physician; Insured’s Authorized Representati...
Expedited External Review. If you have a medical condition where the timeframe for completion of (a) an expedited internal review of an appeal involving an Adverse Determina tion; (b) a Final Adverse Determination; or, (c) a standard external review as described above, would seriously jeopardize your life or health or your abil ity to regain maximum function, then you or your authorized representative may file a request for an expedited external review by an IRO not associated with the Plan. In addition, if a Final Adverse Determination concerns an ad mission, availability of care, continued stay or health care service for which you received emergency services, but have not been discharged from a facil ity, then you or your authorized representative may request an expedited external review. You or your authorized representative may file the request immediately after a receipt of notice of a Final Adverse Determination of if the Plan fails to provide a decision on a request for an expedited internal xx xxxx within 48 hours. You may also request an expedited external review if a Final Adverse De termination concerns a denial of coverage based on the determination that the treatment or service in question is considered experimental or investiga tional and your health care provider certifies in writing that the treatment or service would be significantly less effective if not started promptly. Expedited external review will not be provided for retrospective adverse or final adverse determinations. Your request for an expedited independent external review may be submit xxx to the Director either orally (by calling 877‐850‐4740) or in writing as set forth above for requests for standard external review.
Expedited External Review. A request for an Expedited External Review may be submitted to OCHA after it receives proof from the Member’s Provider that the adverse determination concerns: An inpatient admission; availability of inpatient care; continued stay or health care service for Emergency Services while still admitted to an inpatient facility; or failure to proceed in an expedited manner may jeopardize the life or health of the Member. The OCHA shall approve or deny this request for Expedited External Review within seventy-two (72) hours after receipt of the above required proof. If OCHA approves the request, it shall assign the request to an IRO no later than one (1) business day after approving the request. HPN will supply all relevant medical documents and information used to establish the adverse determination to the IRO within twenty-four (24) hours after receiving notice from the OCHA. The IRO shall complete its Expedited External Review within forty-eight (48) hours after initially being assigned the case unless the Member or the Member’s Authorized Representative and HPN agree to a longer time period. The IRO shall notify the following parties no later than twenty-four (24) hours after completing its Expedited External Review: Member; Member’s Physician; Member’s Authorized Representative, if any; and
Expedited External Review. (Applies to Urgent Care Claims only) If the initial decision of the Plan or the denial resulting from the Plan’s Internal Appeal Process involves an Urgent Care Claim, a Member or health care Provider on behalf of the Member may request an expedited external review of the Plan’s decision. Requests for expedited external review are subject to review by the Plan to determine whether they are timely, complete and eligible for external review. When the request involves a denied Urgent Care Claim, the Plan must complete the preliminary review and provide notice of its eligibility determination immediately upon receipt of the request for expedited external review. If the request is eligible for expedited external review, the Plan must then transmit all necessary documents and information that was considered in denying the Urgent Care Claim involved to an assigned IRO in an expeditious manner. The assigned IRO will conduct the review and provide notice of its final external review decision as expeditiously as the Member’s medical condition or circumstances require, but in no event more than seventy-two (72) hours following receipt by the IRO of the request for expedited external review. If notice of the decision by the IRO is not provided in writing, the IRO must provide within forty-eight (48) hours following initial notice of its final external review decision written confirmation of that decision to the Plan and the Member, or health care Provider filing the expedited external review request on behalf of the Member.
Expedited External Review. A request for an Expedited External Review may be submitted to OCHA after it receives proof from the Insured’s Provider that the adverse determination concerns: An inpatient admission; availability of inpatient care; continued stay or health care service for Emergency Services while still admitted to an inpatient facility; or failure to proceed in an expedited manner may jeopardize the life or health of the Insured. The OCHA shall approve or deny this request for Expedited External Review with seventy-two (72) hours after receipt of the above required proof. If OCHA approves the request, it shall assign the request to an IRO no later than one (1) business day after approving the request. SHL will supply all relevant medical documents and information used to establish the adverse determination to the IRO within twenty-four (24) hours after receiving notice from the OCHA. The IRO shall complete its Expedited External Review within forty-eight (48) hours after initially being assigned the case unless the Insured or the Insured’s Authorized Representative and SHL agree to a longer time period. The IRO shall notify the following parties no later than twenty-four (24) hours after completing its Expedited External Review: Insured; Insured’s Physician; Agreement of Coverage Insured’s Authorized Representative, if any; and SHL. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.
Expedited External Review. The Insured or the Insured’s Authorized Representative may request, in writing, an internal Expedited appeal by SHL and an Expedited External Review from OCHA simultaneously if the adverse determination of the requested or recommended service or treatment is determined by SHL to be experimental, investigational or unproven, and, if the treating Provider certifies, in writing, that such service or treatment would be less effective if not promptly initiated. An oral request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of proof from the Insured’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiated. Upon receipt of such request and proof, the OCHA shall immediately notify SHL accordingly. SHL will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured or the Insured’s Authorized Representative and the OCHA of the determination. If SHL determines the request to be ineligible, the Insured will be notified that the request may be appealed to OCHA.
Expedited External Review. If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative can request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you or your representative of our determination within 24 hours following receipt of the request. What Do You Pay? You are responsible for paying the Annual Deductible stated in the Schedule of Benefits which is attached to your Policy before Benefits for Prescription Drug Products under this Policy are available to you unless otherwise allowed under your Policy. Benefits for PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Benefits for diabetes test strips will be exempt from Co-payment, deductible, and/or Co-insurance. You can obtain up to twelve cycles of a contraceptive at one time. Each cycle is no less than a one-month supply. You are responsible for paying the applicable Co-payment and/or Co-insurance described in the Benefit Information table. You are not responsible for paying a Co-payment and/or Co-insurance for PPACA Zero Cost Share Preventive Care Medications. The Co-payment amount or Co-insurance percentage you pay for a Prescription Drug Product will not exceed the Usual and Customary Charge of the Prescription Drug Product. The amount you pay for any of the following under your Policy will not be included in calculating any Out-of-Pocket Limit stated in your Policy: • Any non-covered drug product. You are responsible for paying 100% of the cost (the amount the pharmacy charges you) for any non-covered drug product. Our contracted rates (our Prescription Drug Charge) will not be available to you. Payment Information NOTE: When Covered Health Care Services are provided by an Indian Health Service provider, your cost share may be reduced. Payment Term And Description Amounts Co-payment and Co-insurance Co-payment Co-payment for a Prescription Drug Product at a Network Pharmacy is a specific dollar amount. Co-insurance Co-insurance for a Prescription Drug Product at a Network Pharmacy is a percentage of the Prescription Drug Charge. Special Programs: We will have certain programs in which you will receive a reduced Co-payment and/or Co- insurance based on your actions such as adherence/compliance to medication or treatment regimens, and/or participation in health mana...
Expedited External Review. A request for an Expedited External Review may be submitted to OCHA after it receives proof from the Insured’s Provider that the adverse determination concerns: An inpatient admission; availability of inpatient care; continued stay or health care service for Emergency Services while still admitted to an inpatient facility; or
Expedited External Review. If you are not satisfied with our determination of your exclusion exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll- free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours. UnitedHealthCare Insurance Company 000 Xxxxxx Xxxxxx Hartford, Connecticut 06103-3408 0-000-000-0000 Disclosure of Minimum Creditable Coverage Standards This benefit plan design meets Minimum Creditable Coverage (MCC) standards and will satisfy the individual Massachusetts mandate that you have health insurance. Please see below for additional information.
Expedited External Review. SAMPLE An expedited external review is similar to a standard external review. The main difference between the two is that the time periods for completing certain portion of the review process are much shorter for the expedited external review, and if both you and UnitedHealthcare agree, you may file an expedited external review before completing the internal appeals process. You or your authorized representative may request an expedited external review with the Commissioner at the time you receive:
