Common use of Preliminary Review Clause in Contracts

Preliminary Review. Within five business days of receipt of the request from the Director, the Plan will complete a preliminary review of your request to determine whether: • You were a covered person at the time health care service was re­ quested or provided; • The service that is the subject of the Adverse Determination or the Fi­ nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ propriate for you; or • There is no available standard health care services or treatment cov­ ered by the Plan that is more beneficial than the recommended or requested service or treatment. • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the DirectorIDOI, the Plan will complete a preliminary review of your request re­ quest to determine whether: • You were a covered person at the time health care service was re­ quested reques­ xxx or provided; • The service that is the subject of the Adverse Determination or the Fi­ nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ propriate appro­ priate for you; or • There is no available standard health care services or treatment cov­ ered covered by the Plan that is more beneficial than the recommended or requested service or treatment. • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the Director, the Plan will complete a preliminary review of your request to determine whether: • You were a covered person at the time health care service was re­ re- quested or provided; • The service that is the subject of the Adverse Determination or the Fi­ Fi- nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ experi- mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ ap- propriate for you; or GB‐16 HCSC 88 • There is no available standard health care services or treatment cov­ cov- ered by the Plan that is more beneficial than the recommended or requested service or treatment. • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ pro- tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the Director, the Plan will complete a preliminary review of your request to determine whether: • You were a covered person at the time health care service was re­ quested or provided; • The service that is the subject of the Adverse Determination or the Fi­ nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ propriate for you; or GB‐16 HCSC 87 • There is no available standard health care services or treatment cov­ ered by the Plan that is more beneficial than the recommended or requested service or treatment. • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the Director, the Plan will complete a preliminary review of your request to determine whether: •  You were a covered person at the time health care service was re­ quested or provided; •  The service that is the subject of the Adverse Determination or the Fi­ nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; •  You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and •  You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: •  Standard health care services or treatments have not been effective in improving your condition; •  Standard health care services or treatments are not medically ap­ propriate for you; or • GB‐16 HCSC 86  There is no available standard health care services or treatment cov­ ered by the Plan that is more beneficial than the recommended or requested service or treatment. •  In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the Director, the Plan will complete a preliminary review of your request to determine whether: • You were a covered person at the time health care service was re­ re- quested or provided; • The service that is the subject of the Adverse Determination or the Fi­ Fi- nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ experi- mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ ap- propriate for you; or • There is no available standard health care services or treatment cov­ cov- ered by the Plan that is more beneficial than the recommended or requested service or treatment. • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ pro- tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the DirectorIDOI, the Plan will complete a preliminary review of your request to determine whether: • You were a covered person an Enrollee at the time health care service was re­ quested requested or provided; • The service that is the subject of the Adverse Determination or the Fi­ nal Final Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental experimental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider Provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ propriate appropriate for you; or • There is no available standard health care services or treatment cov­ ered covered by the Plan that is more beneficial than the recommended or requested service or treatment. • In addition, a) your health care provider Provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care providerProvider, than any available standard health care services or treatments; or b) your health care providerProvider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols protocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the Director, the Plan will complete a preliminary review of your request to determine whether: • You were a covered person at the time health care service was re­ quested or provided; • The service that is the subject of the Adverse Determination or the Fi­ nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ propriate for you; or • There is no available standard health care services or treatment cov­ ered by the Plan that is more beneficial than the recommended or requested service or treatment. ; • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.

Preliminary Review. Within five business days of receipt of the request from the DirectorIDOI, the Plan will complete a preliminary review of your request re­ quest to determine whether: • You were a covered person at the time health care service was re­ quested reques­ xxx or provided; • The service that is the subject of the Adverse Determination or the Fi­ nal Adverse Determination is a Covered Service under this benefit program, but the Plan has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experi­ mental or investigational, the Plan will complete a preliminary review to determine whether the requested service or treatment that is the subject of the Adverse Determination or Final Adverse Determination is a Covered Service, except for the Plan's determination that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit. In addition, your health care provider has certified that one of the following situations is applicable: • Standard health care services or treatments have not been effective in improving your condition; • Standard health care services or treatments are not medically ap­ propriate appro­ priate for you; or • There is no available standard health care services or treatment cov­ ered covered by the Plan that is more beneficial than the recommended or requested service or treatment. ; • In addition, a) your health care provider has certified in writing that the health care service or treatment is likely to be more beneficial to you, in the opinion of your health care provider, than any available standard health care services or treatments; or b) your health care provider, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat your condition has certified in writing that scientifically valid studies using accepted pro­ tocols demonstrate that the health care service or treatment requested is likely to be more beneficial to you than any available standard health care services or treatments.