Common use of EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION Clause in Contracts

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 expedited review process if in the opinion of a physician with knowledge of the Member’s condition, the delay from a standard pre-service review would subject the Member to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. The HMO will conduct an expedited internal review and issue its Final Internal Adverse Benefit Determination within (72) hours of receipt of the request which qualifies for an expedited review. The Member will be notified by telephone of the expedited determination. If the Member is not satisfied with the result of the expedited review, they may seek an expedited external review of the Final Internal Adverse Benefit Determination. The Member also has the right to request expedited external review simultaneously with the expedited internal review.

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 XxxxxxxxxxP.O. Box 779518 Harrisburg, XX 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. 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 expedited review process if in the opinion of a physician with knowledge of the Member’s condition, the delay from a standard pre-service review would subject the Member to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. The HMO will conduct an expedited internal review and issue its Final Internal Adverse Benefit Determination within (72) hours of receipt of the request which qualifies for an expedited review. The Member will be notified by telephone of the expedited determination. If the Member is not satisfied with the result of the expedited review, they may seek an expedited external review of the Final Internal Adverse Benefit Determination. The Member also has the right to request expedited external review simultaneously with the expedited internal review.

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 one (41) months year from receipt of the Notice of Final Adverse Benefit Determination to request an external appeal through an Independent Review Organization to the U.S. Office of Personnel Management (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 OPM) at the following mail address or email address, fax and telephone numbers: HMO MSPP External Grievance Review X.X. Xxx 000000 National Healthcare Operations U.S. Office of Personnel Management 0000 X. Xxxxxx, XX Xxxxxxxxxx, XX 0000000000 e-0000 mail: xxxx@xxx.xxx The Member may request external review after the expiration of the one (1) year period by providing a reasonable explanation for failing to request external review within one (1) year. The Member may phone OPM at the following numbers with questions about the right to external review: Fax: (000-) 000-0000 Toll-free: 0-000-000-0000 TTY: 711 Within five External review is available for denials of coverage based on Medical Necessity including denials for services found to be experimental or investigational, cosmetic, provided in an inappropriate healthcare setting or level of care, provided out of network when available in network, not effective or not justified, or a rescission of coverage. A Member may also have the right to an external review if the plan fails to strictly comply with our internal appeals process and with state and federal requirements for internal appeals. External reviews are facilitated by the federal Office of Personnel Management (5) business days of receipt of OPM). For denials based on the Member’s requestcontract with the HMO, OPM will review and issue a binding determination. If the HMO claim involves an issue of Medical Necessity and appropriateness, OPM will forward the Member’s request appeal to a randomly assigned an Independent Review Organization (IRO). The HMO OPM 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 notify Members that any additional information the Member submits to the IRO OPM within twenty (20) days of OPM’s acceptance of a request for consideration in the external appealreview is guaranteed to be considered. The IRO OPM will notify the Member of its binding decision in writing within forty-five thirty (4530) days from the date of the IRO’s receipt OPM received of the request for external review. External appeals are for appeals For external reviews 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 medical judgment, an IRO will have fifteen (15) calendar days to render a decision after receiving 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 delaysfrom OPM. The HMO will promptly inform the Member and the MemberIRO’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 expedited review process if in the opinion of a physician with knowledge of the Member’s condition, the delay from a standard pre-service review would subject the Member to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. The HMO will conduct an expedited internal review and issue its Final Internal Adverse Benefit Determination within (72) hours of receipt of the request which qualifies for an expedited review. The Member will be notified by telephone of the expedited determination. If the Member is not satisfied with the result of the expedited review, they may seek an expedited external review of the Final Internal Adverse Benefit Determination. The Member also has the right to request expedited external review simultaneously with the expedited internal review.fifteen