Common use of External Appeal Clause in Contracts

External Appeal. After you have exhausted the internal appeal rights provided by Alliant, you have the right to request an external/independent review of this adverse action. You (or your Authorized Representative) may file a written request for an external review. Your notice of Adverse Benefit Determination and Final Adverse Benefit Determination describes the process to follow if you wish to pursue an external appeal. You must submit your request for external review within 123 calendar days of the date you receive the notice of Adverse Benefit Determination or Final Adverse Benefit Determination. You can request an external appeal in writing by sending it electronically to ▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇; or by faxing it to ▇▇▇-▇▇▇-▇▇▇▇, or by sending it by mail to: Office of Personnel Management (OPM) P.O. Box 791 Washington, DC 20044 You may also file an external appeal or complaint with the Georgia Insurance Commissioner’s Office. They will review your appeal or complaint and coordinate an independent external review. Mailing address: Georgia Insurance Commissioner’s Office Consumer Services Division ▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇., Drive Suite 716, West Tower Atlanta, GA 30334 Fax: (▇▇▇) ▇▇▇-▇▇▇▇ If you have any questions or concerns during the external appeal process, you (or your Authorized Representative) can call the toll-free number ▇▇▇-▇▇▇-▇▇▇▇. You (or your representative) can submit additional written comments to the external reviewer at the mailing address above. If any additional information is submitted, it will be shared with Alliant in order to give us an opportunity to reconsider the denial. Request for expedited external appeal – you (or your representative) may make a written or oral request for an expedited external appeal with the external reviewer when you receive:  An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an appeal of an Urgent Care Service would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for a review of an Urgent Care Service; or  A Final Adverse Benefit determination, if you have a Medical Condition where the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received services, but has not been discharged from a facility.  An Adverse Benefit Determination that relates to Experimental or Investigational treatment, if the treating physician certified that the recommended or requested health care service, supply, or treatment would be significantly less effective if not promptly initiated. In expedited external appeal situations, requests for expedited review can be initiated by calling the OPM toll free number ▇▇▇-▇▇▇-▇▇▇▇. Additionally, at Your request, Alliant can send You copies of the actual benefit provision, and will provide a copy at no charge, of the actual benefit, clinical guidelines or clinical criteria used to make the determination upon receipt of Your request. A request can be made by calling the Alliant Complaints and Appeals Coordinator. General rules regarding Alliant’s Complaint and Appeal Process include the following:  You must cooperate fully with Alliant in our effort to promptly review and resolve a complaint or appeal. In the event you do not fully cooperate with Alliant, You will be deemed to have waived your right to have the Complaint or Appeal processed within the time frames set forth above.  Alliant will offer to meet with you by telephone. Appropriate arrangement will be made to allow telephone conferencing to be held at our administrative offices. Alliant will make these telephone arrangements with no additional charge to you.  During the review process, the services in question will be reviewed without regard to the decision reached in the initial determination.  Alliant will provide you with new or additional informational evidence that it considers, relies upon, or generates in connection with an appeal that was not available when the initial Adverse Benefit Determination was made. A “full and fair” review process requires Alliant to send any new medical information to review directly so you have an opportunity to review the claim file.

External Appeal. After you have exhausted the internal appeal rights provided by Alliant, you have the right to request an external/independent review of this adverse action. You (or your Authorized Representative) may file a written request for an external review. Your notice of Adverse Benefit Determination and Final Adverse Benefit Determination describes the process to follow if you wish to pursue an external appeal. You must submit your request for external review within 123 calendar days of the date you receive the notice of Adverse Benefit Determination or Final Adverse Benefit Determination. You can request an external appeal in writing by sending it electronically to ▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇; or by faxing it to ▇▇▇-▇▇▇-▇▇▇▇, or by sending it by mail to: Office of Personnel Management (OPM) P.O. Box 791 Washington, DC 20044 You may also file an external appeal or complaint with the Georgia Insurance Commissioner’s Office. They will review your appeal or complaint and coordinate an independent external review. Mailing address: Georgia Insurance Commissioner’s Office Consumer Services Division ▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇., Drive Suite 716, West Tower Atlanta, GA 30334 Fax: (▇▇▇) ▇▇▇-▇▇▇▇ If you have any questions or concerns during the external appeal process, you (or your Authorized Representative) can call the toll-free number ▇▇▇-▇▇▇-▇▇▇▇. You (or your representative) can submit additional written comments to the external reviewer at the mailing address above. If any additional information is submitted, it will be shared with Alliant in order to give us an opportunity to reconsider the denial. Request for expedited external appeal – you (or your representative) may make a written or oral request for an expedited external appeal with the external reviewer when you receive:  • An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an appeal of an Urgent Care Service would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for a review of an Urgent Care Service; or  • A Final Adverse Benefit determination, if you have a Medical Condition where the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received services, but has not been discharged from a facility.  • An Adverse Benefit Determination that relates to Experimental or Investigational treatment, if the treating physician certified that the recommended or requested health care service, supply, or treatment would be significantly less effective if not promptly initiated. In expedited external appeal situations, requests for expedited review can be initiated by calling the OPM toll free number ▇▇▇-▇▇▇-▇▇▇▇. Additionally, at Your request, Alliant can send You copies of the actual benefit provision, and will provide a copy at no charge, of the actual benefit, clinical guidelines or clinical criteria used to make the determination upon receipt of Your request. A request can be made by calling the Alliant Complaints and Appeals Coordinator. General rules regarding Alliant’s Complaint and Appeal Process include the following:  • You must cooperate fully with Alliant in our effort to promptly review and resolve a complaint or appeal. In the event you do not fully cooperate with Alliant, You will be deemed to have waived your right to have the Complaint or Appeal processed within the time frames set forth above.  • Alliant will offer to meet with you by telephone. Appropriate arrangement will be made to allow telephone conferencing to be held at our administrative offices. Alliant will make these telephone arrangements with no additional charge to you.  • During the review process, the services in question will be reviewed without regard to the decision reached in the initial determination.  • Alliant will provide you with new or additional informational evidence that it considers, relies upon, or generates in connection with an appeal that was not available when the initial Adverse Benefit Determination was made. A “full and fair” review process requires Alliant to send any new medical information to review directly so you have an opportunity to review the claim file.