Common use of External Review Clause in Contracts

External Review. If you are not satisfied with a final internal appeal determination based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, you may have the right to have our decision reviewed by an Independent Review Organization (“IRO”). An IRO is an independent organization of medical reviewers who are certified by the State of Washington Department of Health to review medical and other relevant information. There is no cost to you for an external review. We will send you an External Review Request form, notifying you of your rights to an external review, within 3 business days of the end of the Level II appeal process. We must receive your written request for an external review within 180 days of the date of our final internal adverse benefit determination. Your request must include a signed waiver granting the IRO access to medical records and other materials that are relevant to your request. We will notify the IRO of your request for an external review. We will provide you with the name and contact information of the IRO within 1 day of giving the IRO notice of your request for review. The IRO will accept additional information in writing from you for up to 5 business days from the date we notify them of your request for external review. The IRO is required to consider any information you provide within this period when it conducts its review. The IRO will let you, your authorized representative, if any, or your attending physician know where to submit any additional information and when the information must be provided. We will forward your medical records and other relevant materials for your external review directly to the IRO. We will also provide the IRO with any additional information they request that is reasonably available to us. Once the external review is completed, the IRO will notify you and us in writing of their decision. If you have requested an expedited external review, the IRO will notify you and us of their decision immediately by phone, e-mail or fax after they make their decision, and will follow up with a written decision by mail. CHPW is bound by the decision made by the IRO. If the IRO overturns our final internal adverse benefit determination, we will implement their decision promptly. If the IRO upholds the final internal adverse benefit determination, there is no further review available under this plan's internal appeals or external review process. You may, however, have other remedies available under state or federal law, such as filing a lawsuit.

External Review. If you are not satisfied with wish to contest a final internal appeal decision involving a medical necessity determination based on medical necessityyou may request external review of the decision by an independent organization under contract with the Office of Patient Protection of the Health Policy Commission. You must file the request within 4 months of your receipt of the written notice of the final determination. You may request to have the external review processed as an expedited external review. In this case, appropriateness, the Physician must certify that delay of the health care settingservices for which Benefits have been denied would pose a serious and immediate threat to your health. When a final determination concerns an admission, level availability of care, continued stay, or effectiveness health care service for which the claimant received emergency services, but has not been discharged from a facility, a certification from a health care professional is not necessary to request an expedited external review. You must pay a fee of $25 to the Office of Patient Protection which should be included with the request for a covered benefitreview. The fee may be waived by the Office of Patient Protection if they determine that the payment of the fee would result in an extreme financial hardship to the insured. If the subject matter of the external review involves the termination of ongoing Benefits, you may have apply to the right external review panel to have seek the continuation of Benefits for the terminated service during the period the review is pending. The review panel may order the continuation of Benefits where it determines that substantial harm to your health may result absent such continuation or for such other good cause as the review panel will determine. Any such continuation of coverage shall be at our decision reviewed by an Independent Review Organization (“IRO”)expense regardless of the final external review determination. An IRO The Office of Patient Protection will screen requests for external review to determine whether external review can be granted. If the Office of Patient Protection determines that a request is an independent organization of medical reviewers who are certified by the State of Washington Department of Health to review medical and other relevant information. There is no cost to you eligible for an external review. We , the appeal will send you an External Review Request form, notifying you of your rights be assigned to an external review, within 3 business days review agency and notification will be provided to you (or your representative) and us. The decision of the end of the Level II appeal process. We must receive your written request for an external review within 180 days agency is binding and must be complied with by us. If the Office of the date of our final internal adverse benefit determination. Your Patient Protection determines that a request must include a signed waiver granting the IRO access to medical records and other materials that are relevant to your request. We will notify the IRO of your request for an external review. We will provide you with the name and contact information of the IRO within 1 day of giving the IRO notice of your request for review. The IRO will accept additional information in writing from you for up to 5 business days from the date we notify them of your request is not eligible for external review, you (or your representative) will be notified within 10 business days or, in the case of requests for expedited review, 72 hours. The IRO is required final decision of the review panel will be in writing and set forth the specific medical and scientific reason for the decision and will be furnished to consider any information you provide within this period when it conducts its review. The IRO will let you, or where applicable your authorized representative, if any, or your attending physician know where to submit any additional information and when the information must be provided. We will forward your medical records and other relevant materials for your external review directly to the IRO. We will also provide the IRO with any additional information they request that is reasonably available to us. Once The Office of Patient Protection may be reached at: Health Policy Commission Office of Patient Protection ▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Sample Telephone: ▇-▇▇▇-▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ Web Site: ▇▇▇▇://▇▇▇.▇▇▇▇▇.▇▇.▇▇/hpc/opp/index.htm This plan is subject to state and federal Mental Health Parity laws, which generally prohibit insurance plans from providing mental health or substance use disorder benefits in a more restrictive manner than other medical benefits. If a health plan member believes UnitedHealthcare standards or practices relating to the external review is completedprovision of mental health or substance use disorder benefits are not compliant with applicable mental health parity laws, the IRO will notify you and us health plan member or an authorized representative may submit a complaint to the Division of Insurance at: Division of Insurance ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Suite 810 Boston, MA ▇▇▇▇▇-▇▇▇▇ Telephone: ▇-▇▇▇-▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ TTD/TDD: ▇-▇▇▇-▇▇▇-▇▇▇▇ Complaints may be submitted verbally or in writing of their decisionto the Division’s Consumer Services Section for review. If you have requested an expedited Insurance Complaint Forms can be found on the Division’s webpage at: ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇▇/ocabr/consumer/insurance/file-a-complaint/filing-a-complaint.html Submitting a complaint to the Division does not impact your internal or external review, the IRO will notify you and us of their decision immediately by phone, e-mail or fax after they make their decision, and will follow up with a written decision by mail. CHPW is bound by the decision made by the IRO. If the IRO overturns our final internal adverse benefit determination, we will implement their decision promptly. If the IRO upholds the final internal adverse benefit determination, there is no further review available appeal rights under this plan's internal appeals or external review process. You may, however, have other remedies available under state or federal law, such as filing a lawsuit.

External Review. If you are not satisfied with wish to contest a final internal appeal decision involving a medical necessity determination based on medical necessityyou may request external review of the decision by an independent organization under contract with the Office of Patient Protection of the Health Policy Commission. You must file the request within 4 months of your receipt of the written notice of the final determination. You may request to have the external review processed as an expedited external review. In this case, appropriateness, the Physician must certify that delay of the health care settingservices for which Benefits have been denied would pose a serious and immediate threat to your health. When a final determination concerns an admission, level availability of care, continued stay, or effectiveness health care service for which the claimant received emergency services, but has not been discharged from a facility, a certification from a health care professional is not necessary to request an expedited external review. You must pay a fee of $25 to the Office of Patient Protection which should be included with the request for a covered benefitreview. The fee may be waived by the Office of Patient Protection if they determine that the payment of the fee would result in an extreme financial hardship to the insured. If the subject matter of the external review involves the termination of ongoing Benefits, you may have apply to the right external review panel to have seek the continuation of Benefits for the terminated service during the period the review is pending. The review panel may order the continuation of Benefits where it determines that substantial harm to your health may result absent such continuation or for such other good cause as the review panel will determine. Any such continuation of coverage shall be at our decision reviewed by an Independent Review Organization (“IRO”)expense regardless of the final external review determination. An IRO The Office of Patient Protection will screen requests for external review to determine whether external review can be granted. If the Office of Patient Protection determines that a request is an independent organization of medical reviewers who are certified by the State of Washington Department of Health to review medical and other relevant information. There is no cost to you eligible for an external review. We , the appeal will send you an External Review Request form, notifying you of your rights be assigned to an external review, within 3 business days review agency and notification will be provided to you (or your representative) and us. The decision of the end of the Level II appeal process. We must receive your written request for an external review within 180 days agency is binding and must be complied with by us. If the Office of the date of our final internal adverse benefit determination. Your Patient Protection determines that a request must include a signed waiver granting the IRO access to medical records and other materials that are relevant to your request. We will notify the IRO of your request for an external review. We will provide you with the name and contact information of the IRO within 1 day of giving the IRO notice of your request for review. The IRO will accept additional information in writing from you for up to 5 business days from the date we notify them of your request is not eligible for external review, you (or your representative) will be notified within 10 business days or, in the case of requests for expedited review, 72 hours. The IRO is required final decision of the review panel will be in writing and set forth the specific medical and scientific reason for the decision and will be furnished to consider any information you provide within this period when it conducts its review. The IRO will let you, or where applicable your authorized representative, if any, or your attending physician know where to submit any additional information and when the information must be provided. We will forward your medical records and other relevant materials for your external review directly to the IRO. We will also provide the IRO with any additional information they request that is reasonably available to us. Once The Office of Patient Protection may be reached at: Health Policy Commission Office of Patient Protection ▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Telephone: ▇-▇▇▇-▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ Web Site: ▇▇▇▇://▇▇▇.▇▇▇▇▇.▇▇.▇▇/hpc/opp/index.htm This plan is subject to state and federal Mental Health Parity laws, which generally prohibit insurance plans from providing mental health or substance use disorder benefits in a more restrictive manner than other medical benefits. If a health plan member believes UnitedHealthcare standards or practices relating to the external review is completedprovision of mental health or substance use disorder benefits are not compliant with applicable mental health parity laws, the IRO will notify you and us health plan member or an authorized representative may submit a complaint to the Division of Insurance at: Division of Insurance ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Suite 810 Boston, MA ▇▇▇▇▇-▇▇▇▇ Telephone: ▇-▇▇▇-▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ TTD/TDD: ▇-▇▇▇-▇▇▇-▇▇▇▇ Complaints may be submitted verbally or in writing of their decisionto the Division’s Consumer Services Section for review. If you have requested an expedited Insurance Complaint Forms can be found on the Division’s webpage at: ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇▇/ocabr/consumer/insurance/file-a-complaint/filing-a-complaint.html Submitting a complaint to the Division does not impact your internal or external review, the IRO will notify you and us of their decision immediately by phone, e-mail or fax after they make their decision, and will follow up with a written decision by mail. CHPW is bound by the decision made by the IRO. If the IRO overturns our final internal adverse benefit determination, we will implement their decision promptly. If the IRO upholds the final internal adverse benefit determination, there is no further review available appeal rights under this plan's internal appeals or external review process. You may, however, have other remedies available under state or federal law, such as filing a lawsuit.

External Review. If you are not satisfied dissatisfied with a final internal the Ambetter from Sunshine Health appeal determination based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefitdecision, you may have the right to have our decision reviewed an independent review of certain final decisions made by Ambetter from Sunshine Health. Ambetter from Sunshine Health must pay the cost of the IRO conducting the external review. If you request it, an appeal will be conducted by an Independent Review Organization (“external review organization called an IRO”). An IRO is an independent organization of medical reviewers who are certified not connected in any way with Ambetter from Sunshine Health. Ambetter from Sunshine Health must abide by the State of Washington IRO’s decision and carry out its instructions. You can make a request for external review in writing to Ambetter from Sunshine Health Plan at: Ambetter from Sunshine Health Appeals Department of ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Sunrise, FL 33323 If assistance is needed with completing the written request, you may contact Ambetter from Sunshine Health to review medical and other relevant information. There is no cost to you for an external review. at: Phone ▇▇▇-▇▇▇-▇▇▇▇ TTY/TDD ▇▇▇-▇▇▇-▇▇▇▇ Fax ▇-▇▇▇-▇▇▇-▇▇▇▇ We will send you an External Review Request form, notifying you of your rights request to an external review, the IRO. You must contact the IRO or us within 3 business 120 calendar days of the end of the Level II appeal process. We must receive your written request for an external review within 180 days (4 months) of the date of our final internal adverse benefit determinationyour appeal resolution letter. Your If you do not file your appeal for an external independent review within 120 days, it cannot be reviewed. If you are not sure whether your appeal is eligible, or if you want more information, please contact Ambetter from Sunshine Health. You, or someone you authorized to do so, shall be provided, upon request must include a signed waiver granting and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the IRO access to medical claimant’s claim for benefits. All comments, documents, records and other materials that are relevant to your request. We will notify information submitted by the IRO of your request for an external review. We will provide you with the name and contact information of the IRO within 1 day of giving the IRO notice of your request for review. The IRO will accept additional information in writing from you for up to 5 business days from the date we notify them of your request for external review. The IRO is required to consider any information you provide within this period when it conducts its review. The IRO will let you, your authorized representative, if any, or your attending physician know where to submit any additional information and when the information must be provided. We will forward your medical records and other relevant materials for your external review directly claimant relating to the IRO. We will also provide claim for benefits, regardless of whether such information was submitted or considered in the IRO with any additional information they request that is reasonably available to us. Once the external review is completed, the IRO will notify you and us in writing of their decision. If you have requested an expedited external review, the IRO will notify you and us of their decision immediately by phone, e-mail or fax after they make their decision, and will follow up with a written decision by mail. CHPW is bound by the decision made by the IRO. If the IRO overturns our final internal initial adverse benefit determination, we will implement their decision promptlybe considered in the internal appeal. If the IRO upholds the final internal adverse benefit determination, there is no further review available under this plan's internal appeals or The external review processprocedures apply to any hospital or medical policy or certificate; excluding accident only or disability income only insurance. You may, however, have other remedies External review is available under state or federal law, such as filing a lawsuit.for grievances that involve:

External Review. If you are not satisfied with wish to contest a final internal appeal decision involving a medical necessity determination based on medical necessityyou may request external review of the decision by an independent organization under contract with the Office of Patient Protection of the Health Policy Commission. You must file the request within 4 months of your receipt of the written notice of the final determination. You may request to have the external review processed as an expedited external review. In this case, appropriateness, the Physician must certify that delay of the health care settingservices for which Benefits have been denied would pose a serious and immediate threat to your health. When a final determination concerns an admission, level availability of care, continued stay, or effectiveness health care service for which the claimant received emergency services, but has not been discharged from a facility, a certification from a health care professional is not necessary to request an expedited external review. You must pay a fee of $25 to the Office of Patient Protection which should be included with the request for a covered benefitreview. The fee may be waived by the Office of Patient Protection if they determine that the payment of the fee would result in an extreme financial hardship to the insured. If the subject matter of the external review involves the termination of ongoing Benefits, you may have apply to the right external review panel to have seek the continuation of Benefits for the terminated service during the period the review is pending. The review panel may order the continuation of Benefits where it determines that substantial harm to your health may result absent such continuation or for such other good cause as the review panel will determine. Any such continuation of coverage shall be at our decision reviewed by an Independent Review Organization (“IRO”)expense regardless of the final external review determination. An IRO The Office of Patient Protection will screen requests for external review to determine whether external review can be granted. If the Office of Patient Protection determines that a request is an independent organization of medical reviewers who are certified by the State of Washington Department of Health to review medical and other relevant information. There is no cost to you eligible for an external review. We , the appeal will send you an External Review Request form, notifying you of your rights be assigned to an external review, within 3 business days review agency and notification will be provided to you (or your representative) and us. The decision of the end of the Level II appeal process. We must receive your written request for an external review within 180 days agency is binding and must be complied with by us. If the Office of the date of our final internal adverse benefit determination. Your Patient Protection determines that a request must include a signed waiver granting the IRO access to medical records and other materials that are relevant to your request. We will notify the IRO of your request for an external review. We will provide you with the name and contact information of the IRO within 1 day of giving the IRO notice of your request for review. The IRO will accept additional information in writing from you for up to 5 business days from the date we notify them of your request is not eligible for external review, you (or your representative) will be notified within 10 business days or, in the case of requests for expedited review, 72 hours. The IRO is required final decision of the review panel will be in writing and set forth the specific medical and scientific reason for the decision and will be furnished to consider any information you provide within this period when it conducts its review. The IRO will let you, or where applicable your authorized representative, if any, or your attending physician know where to submit any additional information and when the information must be provided. We will forward your medical records and other relevant materials for your external review directly to the IRO. We will also provide the IRO with any additional information they request that is reasonably available to us. Once The Office of Patient Protection may be reached at: Health Policy Commission SAMPLE Office of Patient Protection ▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Telephone: ▇-▇▇▇-▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ Web Site: ▇▇▇▇://▇▇▇.▇▇▇▇▇.▇▇.▇▇/hpc/opp/index.htm This plan is subject to state and federal Mental Health Parity laws, which generally prohibit insurance plans from providing mental health or substance use disorder benefits in a more restrictive manner than other medical benefits. If a health plan member believes UnitedHealthcare standards or practices relating to the external review is completedprovision of mental health or substance use disorder benefits are not compliant with applicable mental health parity laws, the IRO will notify you and us health plan member or an authorized representative may submit a complaint to the Division of Insurance at: Division of Insurance ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Suite 810 Boston, MA ▇▇▇▇▇-▇▇▇▇ Telephone: ▇-▇▇▇-▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ TTD/TDD: ▇-▇▇▇-▇▇▇-▇▇▇▇ Complaints may be submitted verbally or in writing of their decisionto the Division’s Consumer Services Section for review. If you have requested an expedited Insurance Complaint Forms can be found on the Division’s webpage at: ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇▇/ocabr/consumer/insurance/file-a-complaint/filing-a-complaint.html Submitting a complaint to the Division does not impact your internal or external review, the IRO will notify you and us of their decision immediately by phone, e-mail or fax after they make their decision, and will follow up with a written decision by mail. CHPW is bound by the decision made by the IRO. If the IRO overturns our final internal adverse benefit determination, we will implement their decision promptly. If the IRO upholds the final internal adverse benefit determination, there is no further review available appeal rights under this plan's internal appeals or external review process. You may, however, have other remedies available under state or federal law, such as filing a lawsuit.