Common use of Expedited External Review Clause in Contracts

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 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 Member or the InsuredMember’s Authorized Representative may request in writing, an internal Expedited Appeal by SHL HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and, and  if the treating provider 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 InsuredMember’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiatedOCHA. Upon receipt of such request and proof, OCHA shall immediately notify SHL HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member 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 SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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:  InsuredMember;  InsuredMember’s Physician;  InsuredMember’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.and

Expedited External Review. The Insured Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimentalExperimental, investigational Investigational or unproven or investigationalUnproven, and,  if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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:  InsuredMember;  InsuredMember’s Physician;  InsuredMember’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.and

Expedited External Review. The Insured Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously • if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimentalExperimental, investigational Investigational or unproven or investigationalUnproven, and, • if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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• Member;  Insured• Member’s Physician;  Insured• Member’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.and

Expedited External Review. The Insured Member or the InsuredMember’s Authorized Representative may request in writing, an internal Expedited Appeal by SHL HPN and an Expedited External Review from OCHA simultaneously • if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and, and • if the treating provider 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 InsuredMember’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiatedOCHA. Upon receipt of such request and proof, OCHA shall immediately notify SHL HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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• Member;  Insured• Member’s Physician;  Insured• Member’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.and

Expedited External Review. The Insured or the Insured’s Authorized Representative may request request, in writing, an internal Expedited Appeal 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 experimentalExperimental, investigational Investigational or unproven or investigationalUnproven, and, • if the treating provider 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. 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 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 Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously • if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and, • if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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• Member;  Insured• Member’s Physician;  Insured• Member’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.and

Expedited External Review. The Insured only after the Member has exhausted the internal HPN Appeals Procedures provided under this Plan and if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or the InsuredMember’s Authorized Representative may did not request in writingor agree to a delay or, an internal Expedited Appeal by SHL and an Expedited External Review from OCHA simultaneously if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: • Any medical records of the requested Member relating to the adverse determination; • A copy of the provisions of this Plan upon which the adverse determination was based; • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and • If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or recommended service or treatment is determined by SHL to be experimental, investigational or unproven or investigational, andthe Member’s Authorized Representative, if any additional information is required to conduct the treating provider certifiesreview. If additional information is required, in writingit must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to HPN within one (1) business day after receipt. The IRO shall approve, that modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such service or treatment would be less effective a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the: • Member; • Member’s Physician; • Member’s Authorized Representative, if not promptly initiated. An oral any; and A request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of after it receives proof from the InsuredMember’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 OCHA that such service an inpatient facility; or treatment would be significantly less effective if not promptly initiated• failure to proceed in an expedited manner may jeopardize the life or health of the Member. Upon receipt of such request and proof, The OCHA shall immediately notify SHL accordingly. SHL will immediately determine if the approve or deny this request meets the requirements for Expedited External Review pursuant to this section and notify the Insured or the Insured’s Authorized Representative and OCHA with seventy-two (72) hours after receipt of the determination. If SHL determines the request to be ineligible, the Insured will be notified that the request may be appealed to OCHAabove required proof. If OCHA approves the request for Expedited External Reviewrequest, it shall immediately assign the request to an IRO and notify SHL. The IRO has no later than one (1) business day to select one or more clinical reviewersafter approving the request. SHL must submit the documentation HPN will supply all relevant medical documents and information used to support establish the adverse determination to the IRO within five twenty-four (524) 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 hours after receiving notice of from 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 IROOCHA. The IRO has 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 review the opinion of the clinical reviewers and make a determinationlonger time period. The IRO shall notify the following parties no later than twenty-four (24) hours after completing its Expedited External Review:  Insured• Member;  Insured• Member’s Physician;  Insured• Member’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.and

Expedited External Review. The Insured Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and,  if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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 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 Insured’s Authorized Representative may within four (4) months after receiving notice of an adverse determination subject to this section, submit a request to the OCHA for an External Review. OCHA will notify SHL and/or any other interested parties within one (1) business day after the receipt of the request for External Review. Within five (5) business days after SHL receives such notice and, subject to The Insured or the Insured’s Authorized Representative may request in writing, an internal Expedited Appeal 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 experimental 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, 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. 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 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.eight

Expedited External Review. The Insured Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and,  if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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:  InsuredMember;  InsuredMember’s Physician;  InsuredMember’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.and

Expedited External Review. The Insured or the Insured’s Authorized Representative may request request, in writing, an internal Expedited Appeal 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 investigationalunproven, and,  if the treating provider 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. 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 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 Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously • if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and, • if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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• Member;  Insured• Member’s Physician;  InsuredAgreement of Coverage • Member’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.and

Expedited External Review. The Insured or the Insured’s Authorized Representative may request request, in writing, an internal Expedited Appeal 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 experimentalExperimental, investigational Investigational or unproven or investigationalUnproven, and,  if the treating provider 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. 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 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 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 initiatedOCHA. 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 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 Member or the InsuredMember’s Authorized Representative may request request, in writing, an internal Expedited Appeal appeal by SHL HPN and an Expedited External Review from OCHA simultaneously  if the adverse determination of the requested or recommended service or treatment is determined by SHL HPN to be experimental, investigational or unproven or investigationalunproven, and,  if the treating provider 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 InsuredMember’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 HPN accordingly. SHL HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and notify the Insured Member or the InsuredMember’s Authorized Representative and the OCHA of the determination. If SHL HPN determines the request to be ineligible, the Insured Member will be notified that the request may be appealed to OCHAXXXX. If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify SHLHPN. The IRO has one (1) business day to select one or more clinical reviewers. SHL HPN must submit the documentation used to support the adverse determination to the IRO within five (5) business days. If SHL HPN fails to provide the information within the specified time, the IRO may terminate the External Review and reverse the adverse determination. The Insured Member or InsuredMember’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 Member or the InsuredMember’s Authorized Representative after five (5) business days to the IRO may be considered as well. Any information received by the Insured Member or the InsuredMember’s Authorized Representative must be submitted to SHL HPN 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:  InsuredMember;  InsuredMember’s Physician; Agreement of Coverage  InsuredMember’s Authorized Representative, if any; and  SHLHPN. The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.