How to Request an External Appeal Clause Samples

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. You may also request an external appeal by an outside agency if you are dissatisfied with our appeal determination related to any of the following special circumstances as described in more detail in Section 6: • Emergency room services; • Air ambulance services; • Non-emergency covered healthcare services rendered by a non-network provider at certain network facilities. To request an external appeal related to any of the above scenarios, submit a written request to us within four (4) months of your receipt of the 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
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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.
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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. 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 second level 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) business days, unless it is an urgent appeal, and then you will be notified within two (2) business days. 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, (initial, second level, 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.
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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. 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
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How to Request an External Appeal. If you remain dissatisfied with our dental 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 dental appeal denial letter. We will forward your request to the outside review agency. 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 dentist receives a decision at one of the levels of appeals noted above, (initial or external), the member or dentist may not ask for an appeal at the same level again, unless additional information that could affect such decisions can be provided.
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Related to How to Request an External Appeal

  • 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.

  • Assistance in Litigation or Administrative Proceedings Business Associate shall make itself and any subcontractors, employees or agents assisting Business Associate in the performance of its obligations under this Agreement, available to County at no cost to County to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against County, its Directors, Managers or employees based upon claimed violation of HIPAA, the HIPAA regulations or other laws relating to security and privacy, which involves inactions or actions by the Business Associate, except where Business Associate or its subcontractor, employee or agent is a named adverse party.

  • 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

  • S▇▇▇▇▇▇▇-▇▇▇▇▇; Internal Accounting Controls The Company and the Subsidiaries are in compliance with any and all applicable requirements of the S▇▇▇▇▇▇▇-▇▇▇▇▇ Act of 2002 that are effective as of the date hereof, and any and all applicable rules and regulations promulgated by the Commission thereunder that are effective as of the date hereof and as of the Closing Date. The Company and the Subsidiaries maintain a system of internal accounting controls sufficient to provide reasonable assurance that: (i) transactions are executed in accordance with management’s general or specific authorizations, (ii) transactions are recorded as necessary to permit preparation of financial statements in conformity with GAAP and to maintain asset accountability, (iii) access to assets is permitted only in accordance with management’s general or specific authorization, and (iv) the recorded accountability for assets is compared with the existing assets at reasonable intervals and appropriate action is taken with respect to any differences. The Company and the Subsidiaries have established disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) for the Company and the Subsidiaries and designed such disclosure controls and procedures to ensure that information required to be disclosed by the Company in the reports it files or submits under the Exchange Act is recorded, processed, summarized and reported, within the time periods specified in the Commission’s rules and forms. The Company’s certifying officers have evaluated the effectiveness of the disclosure controls and procedures of the Company and the Subsidiaries as of the end of the period covered by the most recently filed periodic report under the Exchange Act (such date, the “Evaluation Date”). The Company presented in its most recently filed periodic report under the Exchange Act the conclusions of the certifying officers about the effectiveness of the disclosure controls and procedures based on their evaluations as of the Evaluation Date. Since the Evaluation Date, there have been no changes in the internal control over financial reporting (as such term is defined in the Exchange Act) of the Company and its Subsidiaries that have materially affected, or is reasonably likely to materially affect, the internal control over financial reporting of the Company and its Subsidiaries.