External Review definition

External Review means an independent review of an Adverse Benefit Determination conducted by an Independent Review Organization.

External Review means a review that is conducted by an independent review entity which meets specified criteria as established in KRS 304.17A-623, 304.17A-625, and 304.17A-627;

External Review means a review of a non-administrative adverse benefit

Examples of External Review in a sentence

• A request for an Expedited External Review may be submitted to OCHA when the mandatory 1st Level Appeal has been exhausted and after it receives proof from the Insured’s Provider that the adverse determination concerns: • an inpatient admission; • availability of inpatient care; • continued stay or health care service for Emergency Services while still admitted to an inpatient facility; or • failure to proceed in an expedited manner may jeopardize the life or health of the Insured.

• The Insured, or the Insured’s Authorized Representative, has the right to an External Review of the adverse determination under the NSA.

• An oral request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of proof from the Insured’s Provider to OCHA.

• The Insured or the Insured’s Authorized Representative may request in writing, an internal Expedited Appeal by SHL and an Expedited External Review from OCHA simultaneously • if the adverse determination of the requested or recommended service or treatment is determined by SHL to be Experimental, Investigational or Unproven and, • if the treating provider certifies, in writing, that such service or treatment would be less effective if not promptly initiated.

• The IRO shall notify the following parties no later than twenty-four (24) hours after completing its Expedited External Review: • Insured; • Insured’s Physician; • Insured’s Authorized Representative, if any; and • SHL.

More Definitions of External Review

External Review means an independent review of an Adverse Benefit Determination conducted by an Independent Review Organization. External Review is only available for a Final Adverse Benefit Determination based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a Covered Service.

External Review means a review conducted by persons from outside the resource center who represent the specialties that are required to be reviewed.

External Review means a school division-level academic review conducted by an organization or agency at the request of a local school board.

External Review means a review of an adverse benefit determination (including a final internal adverse

External Review means a process, independent of all affected parties, to determine if a health care service is medically necessary or experimental/ investigational.

External Review means a review of an adverse benefit determination by a qualified entity independent of the MCO and State. “External medical review” means a medical necessity review of a denied service request.

External Review means a review by an independent physician as chosen by the Independent Review Organization. “Independent Review Organization” (IRO) means the entity with which the claims administrator has contracted to conduct external reviews for the plan.