EXTERNAL APPEAL PROCEDURE Sample Clauses

The External Appeal Procedure clause establishes a formal process for disputing decisions made by an organization, typically regarding claims or benefits, by allowing an independent third party to review the case. In practice, this clause outlines the steps a claimant must follow to initiate an external appeal, such as submitting required documentation within a specified timeframe and cooperating with the review entity. Its core function is to provide an impartial mechanism for resolving disputes, ensuring fairness and transparency beyond the organization's internal processes.
EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 5 Inpatient Hospital Services B–24 6 Skilled Nursing Facility Services B–27 7 Home Health Care Services B–29 8 Hospice Care Services B–32 9 Mental Health and Substance Use Disorder Services B–34 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–39 12 Prescription Drugs B–43 13 Care Support Programs B–45 14 General Provisions B–46 15 Exclusions and Limitations B–52 SAMPLE
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Related to EXTERNAL APPEAL PROCEDURE

  • External Appeals For appeals of a decision that a prescription drug is not covered because it is not on our formulary, please see the Formulary Exception Process in the Prescription Drug and Diabetic Equipment and Supplies section. When filing a reconsideration or an appeal, please provide the same information listed in the Complaints section above.

  • External Arbitration Procedures Any arbitration initiated under this Agreement shall be conducted before a single neutral arbitrator appointed by the Parties. If the Parties fail to agree upon a single arbitrator within ten

  • How to Request an External Appeal If you remain dissatisfied with our medical appeal determination, you may request an external review by an outside review agency. In accordance with §27-18.9-8, your external appeal will be reviewed by one of the external independent review organizations (IRO) approved by the Office of the Health Insurance Commissioner. The IRO is selected using a rotational method. Your claim does not have to meet a minimum dollar threshold in order for you to be able to request an external appeal. To request an external appeal, submit a written request to us within four (4) months of your receipt of the medical appeal denial letter. We will forward your request to the outside review agency within five (5) business days, unless it is an urgent appeal, and then we will send it within two (2) business days. We may charge you a filing fee up to $25.00 per external appeal, not to exceed $75.00 per plan year. We will refund you if the denial is reversed and will waive the fee if it imposes an undue hardship for you. Upon receipt of the information, the outside review agency will notify you of its determination within ten (10) calendar days, unless it is an urgent appeal, and then you will be notified within seventy-two (72) hours. The determination by the outside review agency is binding on us. Filing an external appeal is voluntary. You may choose to participate in this level of appeal or you may file suit in an appropriate court of law (see Legal Action, below). Once a member or provider receives a decision at one of the several levels of appeals noted above, (reconsideration, appeal, external), the member or provider may not ask for an appeal at the same level again, unless additional information that could affect such decisions can be provided.

  • Appeal Procedures A. Employees may appeal discipline imposed under this LOA through the Dispute Resolution Procedure contained in the Collective Bargaining Agreement (i.e. grievance procedure) or to the Minneapolis Civil Service Commission. B. Concerning disciplinary actions taken pursuant to this drug and alcohol testing LOA, available Civil Service Commission appeal procedures are as follows:

  • Appeal Procedure The Appeal will be deemed an appeal of the entire Arbitration Award. In conducting the Appeal, the Appeal Panel shall conduct a de novo review of all Claims described or otherwise set forth in the Arbitration Notice. Subject to the foregoing and all other provisions of this Paragraph 5, the Appeal Panel shall conduct the Appeal in a manner the Appeal Panel considers appropriate for a fair and expeditious disposition of the Appeal, may hold one or more hearings and permit oral argument, and may review all previous evidence and discovery, together with all briefs, pleadings and other documents filed with the Original Arbitrator (as well as any documents filed with the Appeal Panel pursuant to Paragraph 5.4(a) below). Notwithstanding the foregoing, in connection with the Appeal, the Appeal Panel shall not permit the parties to conduct any additional discovery or raise any new Claims to be arbitrated, shall not permit new witnesses or affidavits, and shall not base any of its findings or determinations on the Original Arbitrator’s findings or the Arbitration Award.