Independent Medical Review. In accordance with 42 CFR 438.204(d), the Agency will provide for an independent review of all Medicaid services provided or arranged by the Contractor. The Contractor shall provide information necessary for the review based upon the requirements of the Agency or the Agency’s independent peer review contractor. The information will include quality outcomes concerning timeliness of, and access to, services covered under the contract. The review will be performed at least annually by an entity outside state government. If the medical audit indicates that quality of care is unacceptable pursuant to contractual requirements, the Agency and the Department may restrict the Contractor’s enrollment activities pending attainment of acceptable quality of care.
Independent Medical Review. External independent review is available to members for review of denials of experimental therapies where such therapies might be indicated for treatment of a life threatening condition or seriously debilitating illness or for denials based on service not being medically necessary by contacting Member Services within five business days of the denial. The request for an independent medical review will be reviewed by the Dental Director or, if necessary, referred to the Quality Assurance Committee. Timeframes for considering independent medical review requests will be the same as for grievance processing. Members have the right to file information in support of the request for independent medical review.
Independent Medical Review. 1. The Member may request review by a certified independent review organization of an Adverse Determination if:
Independent Medical Review. The state regulatory processes available to the Participant in addition to USBHPC’s grievance process to resolve a disputed health care service, as set forth in Article 3 of this Combined Evidence of Coverage and Disclosure Form.
Independent Medical Review. Members have the right to an independent review of decisions by the HMO to deny, modify or delay coverage for health care service(s) based on Medical Necessity (Disputed Health Care Services). Members have the right to an independent medical review of decisions by the HMO to deny coverage for health care services which have been determined by the HMO to be excluded as Experimental and Investigative. Additional information about treatments which will not be excluded as Experimental and Investigative can be found under Transplant Benefits and Additional Benefits – Clinical Cancer Trials, in the Covered Benefits section of the EOC. Section A below describes how Members may request Independent Medical Review for certain Experimental and Investigative treatments related to Life-Threatening or Seriously Debilitating Illnesses. The Department of Managed Health Care will manage the independent medical review process, which is available to Members when they meet the criteria developed by the Department of Managed Health Care. Members are not required to pay any application or processing fees to request or receive independent medical review. Independent medical review is available in addition to HMO Complaint and Appeal procedures and any other remedies available to the Member by law. Members should be aware that the decision not to participate in the independent medical review process may cause the Member to forfeit any statutory right to pursue legal action against the HMO regarding a Disputed Health Care Service.
Independent Medical Review. External independent review is available to members for review of denials of experimental therapies where such therapies might be indicated for treatment of a life threatening condition or seriously debilitating illness or for denials based on service not being medically necessary by contacting Member Services within five business days of the denial. The request for an independent medical review will be reviewed by the Dental Director or, if necessary, referred to the Quality Assurance Committee. Timeframes for considering independent medical review requests will be the same as for grievance processing. Members have the right to file information in support of the request for independent medical review. The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (0-000-000-0000) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not
Independent Medical Review. The Township reserves the right to require the employee to have an independent medical examination by a physician selected by and paid for by the Township at any time when the employee is receiving injured on duty leave, and reserves the right to review the employee’s status every thirty (30) days.
