Common use of Internal Appeal Procedure Clause in Contracts

Internal Appeal Procedure. If You are not satisfied with Our decision regarding Your Grievance, You have the right to submit an Appeal to Us within 180 days of Our decision regarding Your Grievance. You may file an appeal in writing or You may call MDwise Customer Service directly and a Customer Service Representative will assist You in filing the Appeal. We will acknowledge Your Appeal, orally or in writing, within three business days of Our receipt of it. We will continue to provide You with Coverage under this Contract pending the outcome of the Appeal. You may request continuation of Health Services during the Appeal process if an authorized Health Service is being terminate, reduced or suspended before the expiration of the original authorization date. Pre-service authorization requests and re-authorization request after a number of approved number of days, services, or visits expired do not apply. In the event of request for Concurrent Care Claim reviews beyond original authorization, You and Your provider will be notified of the Appeals process, as indicated in Section 8.4. We will document the substance of the Appeal and the actions taken. Your representative may act on Your behalf with respect to requesting an Appeal and the procedures involved. We allow You the opportunity for representation by anyone You choose, including a provider or attorney. For Urgent Grievance Appeals, a health care practitioner with knowledge of Your condition may act as Your representative. We will investigate the substance of the Appeal, including any aspects of clinical care involved. Our Appeal Committee (the Committee) will resolve the Appeal. The Committee shall be comprised of qualified individuals who were not involved in the investigation or resolution of the Grievance or involved in the matters giving rise to it. If the Appeal concerns health care procedures, treatments, or services that have been proposed, refused, or delivered, the Committee shall include one or more individuals who meet all of the following requirements