Common use of Independent Medical Review; Appeals Rights Clause in Contracts

Independent Medical Review; Appeals Rights. HPN may require a Member to have an Independent Medical Review prior to issuing Prior Authorization for any medical benefits. In that case, only a Physician or Chiropractor who is certified to practice in the same field of practice as the primary treating Physician or Chiropractor or who is formally educated in that field will conduct the review. The Independent Medical Review will include a physical exam of the Member and a personal review of all x-rays and reports made by the primary treating Physician or Chiropractor. A certified copy of all reports of findings will be sent to the primary treating Physician or Chiropractor and the Member within ten (10) working days after the review. If the Member disagrees with the findings of the review, he may submit an appeal for binding arbitration to HPN within thirty (30) days after he receives the report. The arbiter will be selected by mutual agreement of HPN and the Member. The cost and expense for filing arbitration shall be paid by the party initiating the demand for arbitration. The arbiter may award arbitration fees, expenses, and compensation in an equitable fashion, in favor of any party. The decision of the arbiter shall be binding upon the Member and HPN, and the arbiter’s ruling shall be enforceable pursuant to state law. Please refer to Section 10, Appeals Procedures in this AOC for more information.

Independent Medical Review; Appeals Rights. HPN may require a Member to have an Independent Medical Review prior to issuing Prior Authorization for any medical benefits. In that case, only a Physician or Chiropractor who is certified to practice in the same field of practice as the primary treating Physician or Chiropractor or who is formally educated in that field will conduct the review. The Independent Medical Review will include a physical exam of the Member and a personal review of all x-rays and reports made by the primary treating Physician or Chiropractor. A certified copy of all reports of findings will be sent to the primary treating Physician or Chiropractor and the Member within ten (10) working days after the review. If the Member disagrees with the findings of the review, he may submit an appeal for binding arbitration to HPN within thirty (30) days after he receives the report. The arbiter will be selected by mutual agreement of HPN and the Member. The cost and expense for filing arbitration shall be paid by the party initiating the demand for arbitration. The arbiter may award arbitration fees, expenses, and compensation in an equitable fashion, in favor of any party. The decision of the arbiter shall be binding upon the Member and HPN, and the arbiter’s ruling shall be enforceable pursuant to state law. Please refer to Section 1011, Appeals Procedures in this AOC for more information.

Independent Medical Review; Appeals Rights. HPN may require a Member to have an Independent Medical Review prior to issuing Prior Authorization for any medical benefits. In that case, only a Physician or Chiropractor who is certified to practice in the same field of practice as the primary treating Physician or Chiropractor or who is formally educated in that field will conduct the review. The Independent Medical Review will include a physical exam of the Member and a personal review of all x-rays and reports made by the primary treating Physician or Chiropractor. A certified copy of all reports of findings will be sent to the primary treating Physician or Chiropractor and the Member within ten (10) working days after the review. If the Member disagrees with the findings of the review, he may submit an appeal for binding arbitration to HPN within thirty (30) days after he receives the report. The arbiter will be selected by mutual agreement of HPN and the Member. The cost and expense for filing arbitration shall be paid by the party initiating the demand for arbitration. The arbiter may award arbitration fees, expenses, and compensation in an equitable fashion, in favor of any party. The decision of the arbiter shall be binding upon the Member and HPN, and the arbiter’s ruling shall be enforceable pursuant to state law. Please refer to Section 10, the Appeals Procedures Section in this AOC for more information.