Standard External Review. The Insured may submit a request for an External Review of an adverse determination under this section only after the Insured has exhausted the internal SHL Appeals Procedures provided under this Plan or if SHL fails to issue a written decision to the Insured within thirty (30) days after the date the appeal was filed, and the Insured or Insured’s Authorized Representative did not request or agree to a delay or, if SHL agrees to permit the Insured to submit the adverse determination to OCHA without requiring the Insured to exhaust all internal SHL appeals procedures. In such event, the Insured shall be considered to have exhausted the internal SHL appeals process. Within five (5) days after OCHA receives a request for External Review, OCHA shall notify the Insured, the Insured’s Authorized Representative and SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: Any medical records of the Insured relating to the adverse determination; A copy of the provisions of this Plan upon which the adverse determination was based; Any documents used and the reason(s) given by SHL’s Managed Care Program for the adverse determination; and If applicable, a list that specifies each Provider who provided healthcare to the Insured and the corresponding medical records from the Provider relating to the adverse determination. Within five (5) days after the IRO receives the required documentation from SHL, they shall notify the Insured or the Insured’s Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional information to SHL within one (1) business day after receipt. The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the: Insured; Insured’s Physician; Insured’s Authorized Representative, if any; and SHL.
Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Director of the Illinois Depart ment of Insurance (“Director”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the Director will send a copy of the request to the Plan.
Standard External Review. The Insured or Insured’s Authorized Representative may within four (4) months after receiving notice of an adverse determination subject to this section, submit a request to the OCHA for an External Review. OCHA will notify SHL and/or any other interested parties within one (1) business day after the receipt of the request for External Review. Within five (5) business days after SHL receives such notice and, subject to applicable Nevada law and regulation and pursuant to this section, SHL will make a preliminary determination of whether the case is complete and eligible for External Review according to Nevada law and regulations. Within one (1) business day of making such a determination, SHL will notify in writing, the Insured or the Insured’s Authorized Representative and OCHA, accordingly. If SHL determines that the case is incomplete and/or ineligible, SHL will notify the Insured in writing of such determination. Such notice shall include the required additional information or materials needed to make the request complete and, if applicable, state the reasons for ineligibility and also state that such determination may be appealed to OCHA. Upon appeal, OCHA may overturn SHL’s determination that a request for External Review of an adverse determination is ineligible, and submit the request to External Review, subject to all of the terms and provisions of this Plan and applicable Nevada law and regulation. Within one (1) business day after receiving the confirmation of eligibility for External Review from SHL, OCHA will assign the IRO accordingly and notify in writing the Insured or the Insured’s Authorized Representative and SHL that the request is complete and eligible for External Review and provide the name of the assigned IRO. SHL, within five (5) days after receipt of such notice from the OCHA, will supply all relevant medical documents and information used to establish the adverse determination to the assigned IRO who will select and assign one or more clinical reviewers to the External Review. The IRO shall approve, modify, or reverse the adverse determination pursuant to this section within twenty (20) days after it receives the information required to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the: • Insured; • Insured’s Physician; • Insured’s Authorized Representative, if any; and • SHL.
Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insur ance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. Your request should be submitted to the IDOI at the following address: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit 000 Xxxx Xxxxxxxxxx Xxxxxx Xxxxxxxxxxx, Xxxxxxxx 00000 (877) 850‐4740 Toll‐free phone (217) 557‐8495 Fax number Xxx.xxxxxxxxxxxxxx@xxxxxxxx.xxx Email address xxxxx://xx.xxxxxxxxx.xxxxxxxx.xxx/xxxxxxxxxxxxx.xxx You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the IDOI will send a copy of the request to the Plan.
Standard External Review. Within four months after the date of receipt of a notice of an adverse determination or final adverse determination, a member or the member’s authorized representative may file a request for an external review with the Director. Within one business day after the date of receipt of a request for external review, the Director shall send a copy of the request to us. The addresses for the Director of Insurance follow: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit 000 X. Xxxxxxxxxx Street Springfield, IL 62767 (000) 000-0000 Toll-free phone (000) 000-0000 Fax number Xxx.xxxxxxxxxxxxxx@xxxxxxxx.xxx xxxxx://xx.xxxxxxxxx.xxxxxxxx.xxx/xxxxxxxxxxxxx.xxx Within five business days following the date of receipt of the external review request, we shall complete a preliminary review of the request to determine whether:
Standard External Review. The Insured may submit a request for an External Review of an adverse determination under this section only after the Insured has exhausted the internal SHL Appeals Procedures provided under this Plan or if SHL fails to issue a written decision to the Insured within thirty (30) days after the date the appeal was filed, and the Insured or Insured’s Authorized Representative did not request or agree to a delay or, if SHL agrees to permit the Insured to submit the adverse determination to OCHA without requiring the Insured to exhaust all internal SHL appeals procedures. In such event, the Insured shall be considered to have exhausted the internal SHL appeals process.
Standard External Review. The Member or Member’s Authorized Representative may within four (4) months after receiving notice of an adverse determination subject to this section, submit a request to the OCHA for an External Review. OCHA will notify HPN and/or any other interested parties within one (1) business day after the receipt of the request for External Review. Within five (5) business days after HPN receives such notice and, subject to applicable Nevada law and regulation and pursuant to this section, HPN will make a preliminary determination of whether the case is complete and eligible for External Review according to Nevada law and regulations.
Standard External Review. The Member or Member’s Authorized Representative may within four (4) months after receiving notice of an adverse
Standard External Review. The Member may submit a request for an External Review of an adverse determination under this section only after • the Member has exhausted the internal HPN Appeals Procedures provided under this Plan or • if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the Member or Member’s Authorized Representative did not request or agree to a delay or, • if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust all internal HPN appeals procedures. In such event, the Member shall be considered to have exhausted the internal HPN appeals process.
Standard External Review. The Member or Member’s Authorized Representative may within four (4) months after receiving notice of an adverse determination subject to this section, submit a request to the OCHA for an External Review.
