INDEPENDENT EXTERNAL REVIEW. You or your authorized representative may make a request for a standard external review or expedited external review of an Adverse Determination or Final Adverse Determination by an independent review organization (IRO).
INDEPENDENT EXTERNAL REVIEW. Appeal decisions involving an Adverse Utilization Determination or an Adverse Health Care Treatment Decision by Health Options are eligible for review by an independent review organization designated by the Maine Bureau of Insurance. Adverse Utilization Determinations for purposes of independent external review include Medical Necessity, appropriateness, health care setting, level of care, effectiveness of a covered Benefit, Experimental or Investigational treatment or services, and rescission. The external review decision must be made within 30 days after the independent review organization receives the request for the review. However, the decision must be made within 72 hours if delay would seriously jeopardize the life or health of the Member or would jeopardize the Member’s ability to regain maximum function. If the independent review organization decides in your favor, the decision is binding on Health Options. Normally, you must first complete Health Options’ first and second level Appeals process to be eligible for independent external review. However, you are not required to complete the first and second level Appeals process if:
INDEPENDENT EXTERNAL REVIEW. A. You have the right to an “independent external review” of an appealable decision made by MVP. An independent external review is an independent review of our decision by a third party known as an independent review organization. Independent review organizations (“IRO”) are selected by the DFR and must not have any conflict of interest associated with the review. You have the right to request a review by a State approved IRO after the first level of internal appeal has been exhausted or after the voluntary second level of appeal where MVP has denied coverage based on medical necessity; experimental or investigational nature of the services; off-label use of a drug; choice of provider; and for mental health and substance abuse reviews. You do not have the right to external review of any other decisions, even if those other decisions affect your eligibility or benefits. Exhaustion of the internal grievance process is not required when MVP has waived the internal grievance process or has been deemed to have waived the internal grievance process by failing to adhere to grievance process time requirements. (An expedited External Appeal can be made simultaneously with an expedited first level of internal appeal.) The right to independent external review is contingent on the Enrollee’s exhaustion of MVP’s first level internal grievance process unless as noted above. You may have the right to an expedited external review if the subject of the review concerns an emergency medical condition, emergency services, or urgently needed care. The timeframes for expedited external reviews are shorter than the timeframes for standard external reviews. You may request an expedited external appeal even if your internal appeal was non-expedited.
INDEPENDENT EXTERNAL REVIEW. Appeal decisions involving an Adverse Utilization Determination or an Adverse Health Care Treatment Decision by Health Options are eligible for review by an independent review organization designated by the Maine Bureau of Insurance. Adverse Utilization Determinations for purposes of independent external review include Medical Necessity, appropriateness, health care setting, level of care, effectiveness of a covered Benefit, Experimental or Investigational treatment or services, and rescission. The external review decision must be made within 30 days after the independent review organ ization receives the request for the review. However, the decision must be made within 72 hours if delay would maximum function. If the independent re view organization decides in your favor, the decision is binding on Health Options. independent external review. However, you are not required to complete the first and second level Appeals process if:
