Assignment of IRO Clause Samples

Assignment of IRO. When the Director receives notice that your re­ quest is eligible for external review following the preliminary review, the Director will, within one business day after the receipt of the notice, a) assign an IRO on a random basis from those IROs approved by the Director; and (b) notify the Plan, you and your authorized representa­ tive, if applicable, of the request's eligibility and acceptance for external review and the name of the IRO. Within five business days after the date of receipt of the notice provided by the Director of assignment of an IRO, the Plan shall provide to the assigned IRO the documents and any information con­ sidered in making the Adverse Determination or Final Adverse Determination. In addition, you or your authorized representative may, within five business days following the date of receipt of the notice of assignment of an IRO, submit in writing to the assigned IRO additional information that the IRO shall consider when conducting the external review. The IRO is not required to, but may, accept and consider addi­ tional information submitted after five business days. If the Plan or its designated utilization review organization does not provide the docu­ ments and information within five business days, the IRO may end the external review and make a decision to reverse the Adverse Deter­ mination or Final Adverse Determination. A failure by the Plan or designated utilization review organization to provide the documents and information to the IRO within five business days shall not delay the conduct of the external review. Within one business day after mak­ ing the decision to end the external review, the IRO shall notify the Plan, you and, if applicable, your authorized representative, of its deci­ sion to reverse the determination. If you or your authorized representative submitted additional informa­ tion to the IRO, the IRO shall forward the additional information to the Plan within one business day of receipt from you or your authorized representative. Upon receipt of such information, the Plan may recon­ sider the Adverse Determination or Final Adverse Determination. Such reconsideration shall not delay the external review. The Plan may end the external review and make a decision to reverse the Adverse Determination or Final Adverse Determination. Within one business day after making the decision to end the external review, the Plan shall notify the Director, the IRO, you, and if applicable, your authorized representative o...