External Appeal definition

External Appeal. An appeal, subsequent to the Contractor’s appeal decision, to the State Fair Hearing process for Medicaid-based adverse decisions.

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External Appeal means an appeal, subsequent to the participating plan appeal decision, to the state fair hearing process for Medicaid-based adverse decisions or to the Medicare process for Medicare-based adverse decisions. The department's external appeal decision shall be binding upon the participating plan and not subject to further appeal by the participating plan.

External Appeal. A Member or authorized representative has the right to request a second level external appeal from DIFS within sixty (60) days of receipt of the decision from the first level internal appeal. The Member or authorized representative initiates the external appeal request by filing the DIFS Health Care Request for External Review Form within sixty (60) days. A copy of the Health Care Request for External Review Form will be included with the final decision letter from the first level internal appeal. Members may also call DIFS at (▇▇▇) ▇▇▇-▇▇▇▇ to receive the form via US mail.

Examples of External Appeal in a sentence

• In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application.

• If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision.

• If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent.

• If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals.

• The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision.

• However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State.

• The External Appeal Agent must notify You in writing of its decision within two (2) business days.

• The External Appeal Agent’s decision is binding on both You and Us. The External Appeal Agent’s decision is admissible in any court proceeding.

• The External Appeal Agent must also notify You in writing of its decision.

• Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision.

More Definitions of External Appeal

External Appeal means an appeal, subsequent to the participating plan internal appeal or reconsideration decision, to the state fair hearing process or internal reconsideration process for adverse decisions. The department's external appeal decision shall be binding upon the participating plan or plans and not subject to further appeal by the participating plan or plans.

External Appeal. An appeal of an adverse Utilization Management benefit determination initiated by the Subscriber (or Dentist acting on behalf of a Subscriber, with the Subscriber’s written consent), consisting of a review by an Independent Utilization Review Organization (IURO).

External Appeal means an appeal, subsequent to the participating plan internal appeal or reconsideration decision, to the state fair hearing process (for a member appeal) or informal appeals process (for a provider appeal).

External Appeal means an appeal researched by a third party organization (“IRO”). The IRO’s decision is final and binding on the plan sponsor.

External Appeal means a request for an independent, external review of the final Adverse Determination made by Anthem through its internal appeal process.