Common use of Standard External Review Clause in Contracts

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after  the Member Insured has exhausted the internal HPN SHL Appeals Procedures provided under this Plan and or  if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or,  if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN SHL appeals procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN SHL appeals process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN 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, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPNSHL’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPNSHL, they shall notify the Member Insured or the MemberInsured’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 HPN 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:  MemberInsured;  MemberInsured’s Physician;  MemberInsured’s Authorized Representative, if any; and  HPNSHL.

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Agreement of Coverage • Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after  the Member Insured has exhausted the all applicable internal HPN SHL Appeals Procedures provided under this Plan and or  if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal Appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or,  if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN appeals proceduresapplicable SHL Appeals Procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN appeals processSHL Appeals Process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN 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, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member Insured relating to the adverse determination;  A copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPNSHL’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.and

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 and 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. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: Agreement of Coverage  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

Standard External Review. The Member Insured may submit a request for an External Review of an adverse determination under this section only after • the Member Insured has exhausted the internal HPN SHL Appeals Procedures provided under this Plan and or • if HPN SHL fails to issue a written decision to the Member Insured within thirty (30) days after the date the appeal was filed, and the Member Insured or MemberInsured’s Authorized Representative did not request or agree to a delay or, • if HPN SHL agrees to permit the Member Insured to submit the adverse determination to OCHA without requiring the Member Insured to exhaust all internal HPN SHL appeals procedures. In such event, the Member Insured shall be considered to have exhausted the internal HPN SHL appeals process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the MemberInsured, the MemberInsured’s Authorized Representative and HPN 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, HPN SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member 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 HPNSHL’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPNSHL, they shall notify the Member Insured or the MemberInsured’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 HPN 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:  Member• Insured;  Member• Insured’s Physician;  Member• Insured’s Authorized Representative, if any; and  HPN• SHL.

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 and 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. Agreement of Coverage Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.and

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 and 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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

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 all applicable internal HPN Appeals Procedures provided under this Plan and or  if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal 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 proceduresAppeals Procedures. In such event, the Member shall be considered to have exhausted the applicable internal HPN appeals processAppeals Process. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member relating to the adverse determination;  A copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.. Evidence of Coverage

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 all applicable internal HPN Appeals Procedures provided under this Plan and or • if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal 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 proceduresAppeals Procedures. In such event, the Member shall be considered to have exhausted the applicable internal HPN appeals processAppeals Process. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member relating to the adverse determination;  • A copy of the provisions of this the healthcare Plan upon which the adverse determination was based;  • Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.. Evidence of Coverage

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 and 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. Within five (5) days after XXXX OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  • Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  • If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  • Member;  • Member’s Physician;  • Member’s Authorized Representative, if any; and  • HPN.

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 and 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, Agreement of Coverage  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. Within five (5) days after XXXX receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized Representative and HPN 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, HPN shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation:  Any medical records of the Member 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 HPN’s Managed Care Program for the adverse determination; and  If applicable, a list that specifies each Provider who provided healthcare to the Member 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 HPN, they shall notify the Member or the Member’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 HPN 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:  Member;  Member’s Physician;  Member’s Authorized Representative, if any; and  HPN.