EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION Sample Clauses

EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION. If a Member is not satisfied upon receiving the Final Internal Adverse Benefit Determination, he or she has four (4) months from receipt to request an external appeal through an Independent Review Organization (IRO). External review is available for appeals from an Adverse Benefit Determination or Final Adverse Benefit Determination that involves medical judgment (including, decisions based on the HMO’s requirements for Medical Necessity and appropriateness, heath care setting, level of care or effectiveness of a covered benefit as well as the HMO’s treatment is experimental /investigational or cosmetic. In order to request an external appeal, the Member must contact the HMO at the following address, fax and telephone numbers: HMO External Grievance Review X.X. Xxx 000000 Xxxxxxxxxx, XX 00000-0000 Fax: 000-000-0000 Toll-free: 0-000-000-0000 TTY: 711 Within five (5) business days of receipt of the Member’s request, the HMO will forward the Member’s request to a randomly assigned IRO. The HMO will forward the documentation pertaining to the denial to the IRO assigned and will simultaneously forward a list of the documents to the Member. The Member may submit additional information to the IRO for consideration in the external appeal. The IRO will notify the Member of its decision in writing within forty-five (45) days from the date of the IRO’s receipt of the request for external review. External appeals are for appeals involving Medical Necessity issues. EXPEDITED REVIEW PROCESS FOR APPEALS OF AN ADVERSE BENEFIT DETERMINATION OR FINAL INTERNAL ADVERSE BENEFIT DETERMINATION INVOLVING URGENT CARE Requests for expedited review may be made at any time in the appeals process. To request an expedited review of an Adverse Benefit Determination or Final Adverse Benefit Determination the Member may call Customer Services at 0-000-000-0000 (TTY: 711). Requests for expedited review should be made by telephone in order to avoid any mail delays. The HMO will promptly inform the Member and the Member’s provider if the request qualifies for expedited review. Internal Expedited Review Process A Member is entitled to request an expedited review process at the time her or she receives an Adverse Benefit Determination which involves a medical condition for which the timeframe for completion of a standard internal review would seriously jeopardize the Member’s life or health or would jeopardize the Member’s ability to regain maximum function. A Member is also entitled to an exp...
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EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION. If a Member is not satisfied upon receiving the Final Internal Adverse Benefit Determination, he or she has four (4) months from receipt to request an external appeal through an Independent Review Organization (IRO). External review is available for appeals from an Adverse Benefit Determination or Final Adverse Benefit Determination that involves medical judgment (including, decisions based on the HMO’s requirements for Medical Necessity, heath care setting, level of care or effectiveness of a covered benefit as well as whether the requested treatment is experimental /investigational or cosmetic or a rescission. In order to request an external appeal, the Member must contact the HMO at the following address, fax and telephone numbers: HMO External Grievance Review P.O. Box 779518 Harrisburg, PA 00000-0000 Fax: 000-000-0000 Toll-free: 0-000-000-0000 TTY: 711 Within five (5) business days of receipt of the Member’s request, the HMO will forward the Member’s request to a randomly assigned IRO. The HMO will forward the documentation pertaining to the denial to the IRO assigned and will simultaneously forward a list of the documents to the Member. The Member may submit additional information to the IRO for consideration in the external appeal. The IRO will notify the Member of its decision in writing within forty-five (45) days from the date of the IRO’s receipt of the request for external review.
Sample 1

Related to EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION

  • Adverse Benefit Determination An adverse benefit determination is any of the following:  Denial of a benefit (in whole or part),  Reduction of a benefit,  Termination of a benefit,  Failure to provide or make a payment (in whole or in part) for a benefit, and  Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.

  • External Review In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact XxXxx’s Member Engagement Center.

  • Internal Investigations (A) The parties recognize that Florida Highway Patrol personnel occupy a special place in American society. Therefore, it is understood that the state has the right to expect that a professional standard of conduct be adhered to by all Florida Highway Patrol personnel regardless of rank or assignment. Since internal investigations may be undertaken to inquire into complaints of Florida Highway Patrol misconduct, the state reserves the right to conduct such investigations to uncover the facts in each case, but expressly agrees to carefully guard and protect the rights and dignity of accused personnel. In the course of an internal investigation, the investigative methods employed will be consistent with the law (including but not limited to section 112.532, Florida Statutes) and this agreement; nothing in this agreement, however, shall be deemed to diminish the rights of employees under applicable law.

  • Internal Control Effective control and accountability must be maintained for all cash, real and personal property, and other assets. Grantee must adequately safeguard all such property and must provide assurance that it is used solely for authorized purposes. Grantee must also have systems in place that provide reasonable assurance that the information is accurate, allowable, and compliant with the terms and conditions of this Agreement. 2 CFR 200.303.

  • Internal Taxation 1. The Parties shall refrain from any measure or practice of an internal fiscal nature establishing, whether directly or indirectly, discrimination between the products of one Party and like products originating in the other Party.

  • How to Request an External Appeal If you remain dissatisfied with our medical appeal determination, you may request an external review by an outside review agency. In accordance with §27-18.9-8, your external appeal will be reviewed by one of the external independent review organizations (IRO) approved by the Office of the Health Insurance Commissioner. The IRO is selected using a rotational method. Your claim does not have to meet a minimum dollar threshold in order for you to be able to request an external appeal. To request an external appeal, submit a written request to us within four (4) months of your receipt of the medical appeal denial letter. We will forward your request to the outside review agency within five (5) business days, unless it is an urgent appeal, and then we will send it within two (2) business days. We may charge you a filing fee up to $25.00 per external appeal, not to exceed $75.00 per plan year. We will refund you if the denial is reversed and will waive the fee if it imposes an undue hardship for you. Upon receipt of the information, the outside review agency will notify you of its determination within ten (10) calendar days, unless it is an urgent appeal, and then you will be notified within seventy-two (72) hours. The determination by the outside review agency is binding on us. Filing an external appeal is voluntary. You may choose to participate in this level of appeal or you may file suit in an appropriate court of law (see Legal Action, below). Once a member or provider receives a decision at one of the several levels of appeals noted above, (reconsideration, appeal, external), the member or provider may not ask for an appeal at the same level again, unless additional information that could affect such decisions can be provided.

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • External Appeals For appeals of a decision that a prescription drug is not covered because it is not on our formulary, please see the Formulary Exception Process in the Prescription Drug and Diabetic Equipment and Supplies section. When filing a reconsideration or an appeal, please provide the same information listed in the Complaints section above.

  • External Audit (a) The Beneficiary or the Executing Agency, as the case may be, shall present to the Bank, during the period of Project execution and within the deadlines and with the frequency provided in the Special Conditions of this Agreement, the Project’s financial statements and other reports, and any additional financial information relating thereto that the Bank may request, in accordance with accounting principles and standards acceptable to the Bank.

  • Internal Audit (1) Within sixty (60) days, the Board shall adopt, implement, and thereafter ensure Bank adherence to an independent, internal audit program sufficient to:

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