Internal Expedited Review Process Sample Clauses

Internal Expedited Review Process. A Member is entitled to request an expedited internal review process at the time her or she receives an Adverse Benefit Determination which involves a medical condition for which the timeframe for completion of a standard internal review would seriously jeopardize the Member’s life or health or would jeopardize the Member’s ability to regain maximum function. A Member is also entitled to an expedited review process if in the opinion of a physician with knowledge of the Member’s condition, the delay from a standard pre-service review would subject the Member to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. The HMO will conduct an expedited internal review and issue its Final Internal Adverse Benefit Determination within forty-eight (48) hours of receipt of the request which qualifies for an expedited review. The Member will be notified by telephone of the expedited determination. If the Member is not satisfied with the result of the expedited review, they may seek an expedited external review of the Final Internal Adverse Benefit Determination. The Member also has the right to request expedited external review simultaneously with the expedited internal review.
Sample 1
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