Independent External Review Clause Samples
The Independent External Review clause establishes a process by which disputes or specific issues arising under the agreement are referred to an impartial third party for evaluation and determination. Typically, this involves appointing an expert or panel who is not affiliated with either party, and whose findings may be binding or advisory depending on the contract terms. This clause serves to provide an objective resolution mechanism, reducing potential bias and helping parties avoid lengthy litigation or arbitration.
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:
a. Health Options has failed to make a decision on your first or second level Appeal in the time frames noted above;
Independent External Review. Enrollees may request an independent external review within one hundred twenty (120) Calendar Days of notification that an appealed Adverse Benefit Determination has been upheld or when the Appeal process has been deemed exhausted by way of Insurer’s failure to adhere to the notification and timing requirements of 42 CFR 457.1260 which incorporates 42 CFR 438.408. Insurer shall maintain a contract with an Independent Review Organization (IRO) for the provision of Enrollees’ option to have a post-appeal independent review. Such contract shall specify and meet all state and federal laws, regulations and guidance applicable to CHIP Grievance and Appeal process requirements and subcontractor requirements, including FHKC’s audit rights. Insurer shall provide a quarterly report listing all independent reviews the IRO handled in the quarter, including the date the independent review was requested, the date the IRO made a final decision, the outcome of the review, whether Insurer has since received any Grievances related to the independent review and any other information requested by FHKC. Enrollees and the Enrollee’s representative or the legal representative of a deceased ▇▇▇▇▇▇▇▇’s estate shall be included as parties to the review. In the event the independent external review overturns an Adverse Benefit Determination, Insurer shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires, but no later than seventy-two (72) hours from the independent external review determination date. Insurer is responsible for the full cost of all independent reviews.
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:
a. Health Options has failed to make a decision on your first or second level Appeal in the time frames noted above;
b. internal Appeal process;
c. You have appli ed for expedited external review at the same time as applying for an expedited internal Appeal;
d. You and Health Options mutually agree to bypass the Health Options Appeals process, or with respect to a second level Appeal you waive your right to a second l evel Appeal;
e. Your life or health is in serious jeopardy;
f. The Member for whom external review is requested has died; or
g. The Adverse Utilization Determination or Adverse Health Care Treatment Decision concerns an admission, availability of care, a continu ed stay, or health care services when the Member has received Medical Emergency services but has not been discharged from the facility that provided the Medical Emergency services. You may obtain review under this section even though you have failed to o btain Prior Approval prior to receiving a Covered Service. You must request external review by making your request in writing to the Maine Bureau of Insurance at ▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇. You must also make your request within 12 months a fter
a. Has your written consent to make the request;
b. Is authorized by law to make the request on your behalf; or
c. Is your family member or treating Provider, but only if you are unable to make the request.