Common use of IRO's Decision Clause in Contracts

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriate: • Your pertinent medical records; • Your health care provider's recommendation; • Consulting reports from appropriate health care providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating provider; • The terms of coverage under the benefit program; • The most appropriate practice guidelines, which shall include appli­ cable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ sional medical societies, boards and associations; • Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and • The opinion of the IRO's clinical reviewer or reviewers after consid­ eration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ mended or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct the external review, which clinical reviewers must meet the minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ able, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ternal review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the Director, the Plan, you and your authorized repres­ entative, if applicable, of its decision. The written notice will include:

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriate: • Your pertinent medical records; • Your health care providerProvider's recommendation; • Consulting reports from appropriate health care providers Providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating provider; • The terms of coverage under the benefit program; • The most appropriate practice guidelines, which shall include appli­ cable ap­ plicable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ sional professional medical societies, boards and associations; • Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and • The opinion of the IRO's clinical reviewer or reviewers after consid­ eration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ mended recommen­ ded or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct con­ duct the external review, which clinical reviewers must meet the minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ able, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ternal review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the DirectorIDOI, the Plan, you and your authorized repres­ entativerepresent­ ative, if applicable, of its decision. With respect to experimental or investigational services or treatments, the IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. The written notice will include:

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriateappropriate: • Your pertinent medical records; • Your health care providerProvider's recommendation; • Consulting reports from appropriate health care providers Providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating providerProvider; • The terms of coverage under the benefit program; • The most appropriate practice guidelines, which shall include appli­ cable applicable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ sional professional medical societies, boards and associations; • Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and • The opinion of the IRO's clinical reviewer or reviewers after consid­ eration consideration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ mended recommended or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct the external review, which clinical reviewers must meet the minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ ableapplicable, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ternal external review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the DirectorIDOI, the Plan, you and your authorized repres­ entativerepresentative, if applicable, of its decision. With respect to experimental or investigational services or treatments, the IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. The written notice will include:

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ ap- propriate: • Your pertinent medical records; • Your health care provider's recommendation; • Consulting reports from appropriate health care providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating provider; • The terms of coverage under the benefit program; • The most appropriate practice guidelines, which shall include appli­ appli- cable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ profes- sional medical societies, boards and associations; • Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and • The opinion of the IRO's clinical reviewer or reviewers after consid­ consid- eration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ recom- mended or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct the external review, which clinical reviewers must meet the minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ applic- able, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ex- ternal review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the Director, the Plan, you and your authorized repres­ repres- entative, if applicable, of its decision. The written notice will include:

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriate: • Your pertinent medical records; • Your health care provider's recommendation; • Consulting reports from appropriate health care providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating provider; • The terms of coverage under the benefit program; • The most appropriate practice guidelines, which shall include appli­ cable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ sional medical societies, boards and associations; • Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and • The opinion of the IRO's clinical reviewer or reviewers after consid­ eration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ mended or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct the external review, which clinical reviewers must meet the GB‐16 HCSC 89 minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ able, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ternal review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the Director, the Plan, you and your authorized repres­ entative, if applicable, of its decision. The written notice will include:

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriate: •  Your pertinent medical records; •  Your health care provider's recommendation; •  Consulting reports from appropriate health care providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating provider; •  The terms of coverage under the benefit program; •  The most appropriate practice guidelines, which shall include appli­ cable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ sional medical societies, boards and associations; •  Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and •  The opinion of the IRO's clinical reviewer or reviewers after consid­ eration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ mended or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct the external review, which clinical reviewers must meet the GB‐16 HCSC 88 minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ able, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ternal review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the Director, the Plan, you and your authorized repres­ entative, if applicable, of its decision. The written notice will include:

IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ ap- propriate: • Your pertinent medical records; • Your health care provider's recommendation; • Consulting reports from appropriate health care providers and other documents submitted to the Plan or its designated utilization review organization, you, your authorized representative or your treating provider; • The terms of coverage under the benefit program; • The most appropriate practice guidelines, which shall include appli­ appli- cable evidence–based standards and may include any other practice guidelines developed by the federal government, national or profes­ profes- sional medical societies, boards and associations; • Any applicable clinical review criteria developed and used by the Plan or its designated utilization review organization; and • The opinion of the IRO's clinical reviewer or reviewers after consid­ consid- eration of the items described above. Within one business day after the receipt of notice of assignment to conduct an external review with respect to a denial of coverage based on a determination that the health care service or treatment recom­ recom- mended or requested is experimental or investigational, the IRO will select one or more clinical reviewers, as it determines is appropriate, to conduct the external review, which clinical reviewers must meet the GB‐16 HCSC 90 minimum qualifications set forth in the Illinois Health Carrier External Review Act, and neither you, your authorized representative, if applic­ applic- able, nor the Plan will choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review. Each clinical reviewer will provide a written opinion to the IRO within 20 days after being selected by the IRO to conduct the ex­ ex- ternal review on whether the recommended or requested health care service or treatment should be covered. The IRO will make a decision within 20 days after the date it receives the opinion of each clinical reviewer, which will be determined by the recommendation of a majority of the clinical reviewers. Within five days after the date of receipt of the necessary information, but in no event more than 45 days after the date of receipt of request for an external review, the IRO will render its decision to uphold or reverse the Adverse Determination or Final Adverse Determination and will notify the Director, the Plan, you and your authorized repres­ repres- entative, if applicable, of its decision. The written notice will include: