Common use of External Independent Medical Review Clause in Contracts

External Independent Medical Review. If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for which cov- erage coverage was denied by Blue Shield of California or by a con- tracting contracting provider in whole or in part on the grounds that the service is not Medically Necessary Neces- sary or is experi- mentalexperimental/investigational (including the external review availa- ble available under the Xxxxxxxx-Xxxxxxxx- Xxxxxxx Experimental Treatment Act of 1996), you . Members may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx mat- ter submitted to an independent agency for external exter- nal review in accord- ance accordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external review; however, if your the matter would qualify for an expedited decision as described de- scribed above or involves a determi- nation determination that the requested service is experi- mentalexperimental/investigational, you a Member may immediately request an ex- ternal review external re- view following receipt of notice of denial. You A Mem- ber may initiate this review by completing an application ap- plication for external review, a copy of which can be obtained by contact- ing contacting Customer Service. The Department of Managed Health Care will review re- view the application and, if the request qualifies for external review, will select an external review agency and have your the Member’s records submitted to a qualified specialist for an independent determination deter- mination of whether the care is Medically NecessaryNeces- sary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external reviewre- view. You The Member and your the Member’s physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding on Blue Shield; if the external re- viewer reviewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures procedures or remedies available to you and is completely volun- tary on your partcom- pletely voluntary; you Members are not obligated to request re- quest external review. However, failure to participate partici- xxxx in external review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information regarding the external re- view process, or to request an application form, please con- tact contact Customer Service.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for which cov- erage coverage was denied by Blue Shield of California or by a con- tracting contracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mentalexperimental/investigational (including the external review availa- ble available under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you Members may choose to make a request to the De- partment Department of Managed Health Care to have the matter submit- xxx submitted to an independent agency for external review in accord- ance accordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external review; however, if your the matter would qualify for an expedited decision as described above or involves a determi- nation determination that the requested service is experi- mentalexperimental/investigational, you a Member may immediately request an ex- ternal external review following receipt of notice of denial. You A Member may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your the Member’s records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external review. You The Member and your the Member’s physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding on Blue Shield; if the external re- viewer reviewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures procedures or remedies available to you and is completely volun- tary on your partvoluntary; you Members are not obligated to request external review. However, failure to participate in external review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information regarding the external re- view review process, or to request an application form, please con- tact contact Customer Service.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for which cov- erage coverage was denied by Blue Shield of California or by a con- tracting contracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mentalexperimental/investigational (including the external ex- ternal review availa- ble available under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you Members may choose to make a request to the De- partment Department of Managed Health Care to have the matter submit- xxx submitted to an independent agency for external review in accord- ance ac- cordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external reviewre- view; however, if your the matter would qualify for an expedited ex- pedited decision as described above or involves a determi- nation de- termination that the requested service is experi- mentalexperimen- tal/investigational, you a Member may immediately request re- quest an ex- ternal external review following receipt of notice of denial. You A Member may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies quali- fies for external review, will select an external review re- view agency and have your the Member’s records submitted submit- xxx to a qualified specialist for an independent determination deter- mination of whether the care is Medically Necessary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external review. You The Member and your physician the Member’s Physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding bind- ing on Blue Shield; if the external re- viewer determines reviewer deter- mines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external ex- ternal review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your partvol- untary; you Members are not obligated to request external exter- nal review. However, failure to participate in external exter- nal review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information in- formation regarding the external re- view review process, or to request an application form, please con- tact Customer contact Cus- tomer Service. Department of Managed Health Care Review The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s griev- ance process before contacting the Department. Uti- lizing this grievance procedure does not prohibit any potential legal rights or remedies that may be avail- able to you. If you need help with a grievance involv- ing an emergency, a grievance that has not been sat- isfactorily resolved by your health plan, or a griev- ance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medi- cal Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the Medical Necessity of a proposed service or treat- ment, coverage decisions for treatments that are ex- perimental or investigational in nature, and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone num- ber (0-000-000-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The De- partment’s internet website, (xxx.xxxx.xx.xxx), has complaint forms, IMR application forms, and in- structions online. In the event that Blue Shield should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Depen- dents may request a review by the Department of Managed Health Care Director.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for which cov- erage coverage was denied by Blue Shield of California or by a con- tracting contracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mentalexperimental/investigational (including the external ex- ternal review availa- ble available under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you Members may choose to make a request to the De- partment Department of Managed Health Care to have the matter submit- xxx submitted to an independent agency for external review in accord- ance ac- cordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external reviewre- view; however, if your the matter would qualify for an expedited ex- pedited decision as described above or involves a determi- nation de- termination that the requested service is experi- mentalexperimen- tal/investigational, you a Member may immediately request re- quest an ex- ternal external review following receipt of notice of denial. You A Member may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing contacting Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies quali- fies for external review, will select an external review re- view agency and have your the Member’s records submitted submit- xxx to a qualified specialist for an independent determination deter- mination of whether the care is Medically Necessary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external review. You The Member and your physician the Member’s Physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding bind- ing on Blue Shield; if the external re- viewer determines reviewer deter- mines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external ex- ternal review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your partvol- untary; you Members are not obligated to request external exter- nal review. However, failure to participate in external exter- nal review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information in- formation regarding the external re- view review process, or to request an application form, please con- tact Customer contact Cus- tomer Service. Department of Managed Health Care Review The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s griev- ance process before contacting the Department. Uti- lizing this grievance procedure does not prohibit any potential legal rights or remedies that may be avail- able to you. If you need help with a grievance involv- ing an emergency, a grievance that has not been sat- isfactorily resolved by your health plan, or a griev- ance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medi- cal Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the Medical Necessity of a proposed service or treat- ment, coverage decisions for treatments that are ex- perimental or investigational in nature, and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone num- ber (0-000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The De- partment’s Internet Web site, (www.hmo- xxxx.xx.xxx), has complaint forms, IMR application forms, and instructions online. In the event that Blue Shield should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Depen- dents may request a review by the Department of Managed Health Care Director.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for For more information regarding the external re- view process, or to request an application form, please contact Customer Service. which cov- erage coverage was denied by Blue Shield of California or by a con- tracting x contracting provider in whole or in part on the grounds that the service is not Medically Necessary Neces- sary or is experi- mentalexperimental/investigational (including the external review availa- ble available under the Xxxxxxxx-Xxxxxxxx- Xxxxxxx Experimental Treatment Act of 1996), you . Members may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx mat- ter submitted to an independent agency for external exter- nal review in accord- ance accordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external review; however, if your the matter would qualify for an expedited decision as described de- scribed above or involves a determi- nation determination that the requested service is experi- mentalexperimental/investigational, you a Member may immediately request an ex- ternal review external re- view following receipt of notice of denial. You A Mem- ber may initiate this review by completing an application ap- plication for external review, a copy of which can be obtained by contact- ing contacting Customer Service. The Department of Managed Health Care will review re- view the application and, if the request qualifies for external review, will select an external review agency and have your the Member’s records submitted to a qualified specialist for an independent determination deter- mination of whether the care is Medically NecessaryNeces- sary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external reviewre- view. You The Member and your the Member’s physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding on Blue Shield; if the external re- viewer reviewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures procedures or remedies available to you and is completely volun- tary on your partcom- pletely voluntary; you Members are not obligated to request re- quest external review. However, failure to participate partici- xxxx in external review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service.

External Independent Medical Review. If your grievance involves a claim or services for which cov- erage coverage was denied by Blue Shield of California or by a con- tracting provider in whole or in part by Blue Shield on the grounds that the service is not Medically Necessary or is experi- mentalexperimental/investigational (including the external review availa- ble available under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx submitted to an independent agency for external review in accord- ance accordance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigationalabove, you may immediately request an ex- ternal review following receipt of notice of denialexternal review. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Servicecontacting Member Services. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist the agency for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for reviewopinion. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding on Blue Shield; if the external re- viewer reviewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures procedures or remedies available to you and is completely volun- tary voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information regarding the external re- view review process, or to request an application form, please con- tact Customer Servicecontact Member Services.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for which cov- erage coverage was denied by Blue Shield of California or by a con- tracting contracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mentalexperimental/investigational (including the external ex- ternal review availa- ble available under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you Members may choose to make a request to the De- partment Department of Managed Health Care to have the matter submit- xxx submitted to an independent agency for external review in accord- ance ac- cordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external reviewre- view; however, if your the matter would qualify for an expedited ex- pedited decision as described above or involves a determi- nation de- termination that the requested service is experi- mentalexperimen- tal/investigational, you a Member may immediately request re- quest an ex- ternal external review following receipt of notice of denial. You A Member may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Servicecontacting Shield Concierge. The Department of Managed Health Care will review the application and, if the request qualifies quali- fies for external review, will select an external review re- view agency and have your the Member’s records submitted submit- xxx to a qualified specialist for an independent determination deter- mination of whether the care is Medically Necessary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external review. You The Member and your physician the Member’s Physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding bind- ing on Blue Shield; if the external re- viewer determines reviewer deter- mines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external ex- ternal review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your partvol- untary; you Members are not obligated to request external exter- nal review. However, failure to participate in external exter- nal review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information in- formation regarding the external re- view review process, or to request an application form, please con- tact Customer Servicecontact Shield Concierge.

External Independent Medical Review. If your grievance involves a claim For grievances involving claims or services for For more information regarding the external re- view process, or to request an application form, please contact Customer Service. which cov- erage coverage was denied by Blue Shield of California or by a con- tracting contracting provider in whole or in part on the grounds that the service is not Medically Necessary Neces- sary or is experi- mentalexperimental/investigational (including the external review availa- ble available under the Xxxxxxxx-Xxxxxxxx- Xxxxxxx Experimental Treatment Act of 1996), you . Members may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx mat- ter submitted to an independent agency for external exter- nal review in accord- ance accordance with California law. You Members normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request requesting external review; however, if your the matter would qualify for an expedited decision as described de- scribed above or involves a determi- nation determination that the requested service is experi- mentalexperimental/investigational, you a Member may immediately request an ex- ternal review external re- view following receipt of notice of denial. You A Mem- ber may initiate this review by completing an application ap- plication for external review, a copy of which can be obtained by contact- ing contacting Customer Service. The Department of Managed Health Care will review re- view the application and, if the request qualifies for external review, will select an external review agency and have your the Member’s records submitted to a qualified specialist for an independent determination deter- mination of whether the care is Medically NecessaryNeces- sary. You Members may choose to submit additional records to the external review agency for review. There is no cost to you the Member for this external reviewre- view. You The Member and your the Member’s physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding on Blue Shield; if the external re- viewer reviewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided provided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures procedures or remedies available to you and is completely volun- tary on your partcom- pletely voluntary; you Members are not obligated to request re- quest external review. However, failure to participate partici- xxxx in external review may cause you the Member to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed disputed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service.

External Independent Medical Review. If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider contracting Provider in whole or in part on the grounds that the service is not Medically Med- ically Necessary or is experi- mentalExperimental/investigational Investigational (including the external review availa- ble available under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment Department of Managed Health Care to have the matter submit- xxx submitted to an independent agency for external exter- nal review in accord- ance accordance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described de- scribed above or involves a determi- nation determination that the requested service is experi- mentalExperimental/investigationalInvestigational, you may immediately request an ex- ternal external review following receipt of notice of denialdeni- al. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Servicecon- tacting Member Services. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist special- ist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician Physician will receive copies of the opinions of the external review agency. The decision of the external re- view review agency is binding on Blue Shield; if the external re- viewer reviewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service Service to be pro- vided provided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures procedures or remedies available to you and is completely volun- tary com- pletely voluntary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed servicedisputed ser- vice. For more information regarding the external re- view review process, or to request an application form, please con- tact Customer Servicecontact Member Services. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health Plan, you should first tele- phone your health Plan at the number provided on the last page of this booklet and use your health Plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health Plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experi- mental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0-000-XXX-0000) and a TDD line (0-000-000-0000) for the hearing and speech impaired. The Department’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to health or utilization of Benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.