External Appeal Clause Samples

External Appeal. If you remain dissatisfied with our appeal determination, you may request an external review by an outside review agency for any claim amount. There is no minimum dollar amount that a claim must be in order to file an external appeal. To request an external review you must submit your request in writing to us within four (4) months of your receipt of the determination. We will forward your request to the outside review agency within five (5) business days, or two (2) business days for an expedited external appeal. We may charge you a filing fee up to $25.00 per external appeal, not to exceed $75.00 per benefit year. We will refund you if the denial is reversed and will waive the fee if it imposes an undue hardship on you. For all non-emergency appeals, the outside review agency will notify you of its determination within ten (10) business days of the agency’s receipt of the information. For all urgent external appeals, the outside review agency will notify you of its determination within two (2) business days. The determination by the outside review agency is binding upon us. This External Appeal is voluntary. This means you may choose to participate in this level of appeal or you may file suit in an appropriate court of law (Please see Section 7.4 Legal Action, below).

External Appeal. An Appeal, subsequent to the ICO Appeal decision, to the State Fair Hearing process for Medicaid-based Adverse Action or the Medicare process for Medicare-based Adverse Action.

External Appeal. An Appeal, subsequent to the Contractor’s Appeal decision, to the State Fair Hearing process for Medicaid-based Adverse Benefit Determinations or the Medicare process for Medicare-based Adverse Benefit Determinations.

External Appeal. An Appeal, subsequent to the STAR+PLUS MMP Appeal decision, to the HHSC Fair Hearing process for Medicaid-based Adverse Benefit Determinations, or to the Medicare Independent Review Entity (IRE) process for Medicare-based Adverse Benefit Determinations. 247 1.66. External Quality Review Organization (EQRO) – An independent entity that contracts with the State and evaluates the access, timeliness, and quality of care delivered by the STAR+PLUS MMP to their Enrollees. 247

External Appeal. Provided that a Member has first made recourse to the provisions of this Agreement, the decision of the Board shall not preclude recourse by the Member to the ordinary courts.

External Appeal. 4.1 If the employee does not agree with the decision of the internal appeal, he may within three months following notification thereof call on the services of an expert from his labor union that is a party to this CLA. This expert may consult with an expert to be appointed by the employer on the issue as to whether the job has been correctly classified. In the case of a job that is graded according to the ORBA method, an expert from the AWVN will be called upon. 4.2 A joint ruling by these experts will be binding and will be conveyed by the employer to the person concerned in writing. If the employee is not affiliated to a labor union, the ruling on the classification of an ORBA job will be issued by an expert from the AWVN. 4.3 The period of assessment for an external appeal is generally no more than three months.

External Appeal. After you have exhausted the internal appeal rights provided by Alliant, you have the right to request an external/independent review of this adverse action. You (or your Authorized Representative) may file a written request for an external review. Your notice of Adverse Benefit Determination and Final Adverse Benefit Determination describes the process to follow if you wish to pursue an external appeal. You must submit your request for external review within 123 calendar days of the date you receive the notice of Adverse Benefit Determination or Final Adverse Benefit Determination. You can request an external appeal in writing by sending it electronically to ▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇; or by faxing it to ▇▇▇-▇▇▇-▇▇▇▇, or by sending it by mail to: Office of Personnel Management (OPM) P.O. Box 791 Washington, DC 20044 You may also file an external appeal or complaint with the Georgia Insurance Commissioner’s Office. They will review your appeal or complaint and coordinate an independent external review. Mailing address: Georgia Insurance Commissioner’s Office Consumer Services Division ▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇., Drive Suite 716, West Tower Atlanta, GA 30334 Fax: (▇▇▇) ▇▇▇-▇▇▇▇ If you have any questions or concerns during the external appeal process, you (or your Authorized Representative) can call the toll-free number ▇▇▇-▇▇▇-▇▇▇▇. You (or your representative) can submit additional written comments to the external reviewer at the mailing address above. If any additional information is submitted, it will be shared with Alliant in order to give us an opportunity to reconsider the denial. Request for expedited external appeal – you (or your representative) may make a written or oral request for an expedited external appeal with the external reviewer when you receive:  An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an appeal of an Urgent Care Service would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for a review of an Urgent Care Service; or  A Final Adverse Benefit determination, if you have a Medical Condition where the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns an admission, availability of care, continu...

External Appeal. A. Your Right to an External Appeal. In some cases, You have a right to an external appeal of a denial of coverage. 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. In order for You to be eligible for an external appeal You must meet the following two (2) requirements: • The service, procedure, or treatment must otherwise be a Covered Service under this Contract; and • In general, You must have received a final adverse determination through Our internal Appeal process. But, You can file an external appeal even though You have not received a final adverse determination through Our internal Appeal process if: o We agree in writing to waive the internal Appeal. We are not required to agree to Your request to waive the internal Appeal; or o You file an external appeal at the same time as You apply for an expedited internal Appeal; or o We fail to adhere to Utilization Review claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to You, and We demonstrate that the violation was for good cause or due to matters beyond Our control and the violation occurred during an ongoing, good faith exchange of information between You and Us).

External Appeal. An Appeal, subsequent to the ICO Appeal decision, to the State Fair Hearing process for Medicaid-based Adverse Benefit Determination, or the Medicare process for Medicare-based Adverse Benefit Determination. External Quality Review Organization (EQRO) – An independent entity that contracts with the State and evaluates the access, timeliness, and quality of care delivered by ICOs to their Enrollees. Federally-Qualified Health Center (FQHC) — an entity that satisfies the criteria set forth in 42 U.S.C. § 1396d(l)(2)(B); includes Rural Health Centers (RHCs) as defined in Section 1861(aa) (2) of the Social Security Act