IRO's Decision Clause Samples

The 'IRO's Decision' clause establishes that the determination made by the Independent Review Organization (IRO) is final and binding regarding a specific dispute or issue. In practice, this means that when parties disagree on a matter covered by the contract, the IRO is called upon to review the facts and make a decision, which both parties must accept without further appeal. This clause ensures a clear and authoritative resolution process, reducing prolonged disputes and providing certainty for both parties.
IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriate: 1. A general description of the reason for the request for external review; 2. The date the IRO received the assignment from the Director; 3. The time period during which the external review was con­ ducted; 4. References to the evidence or documentation including the evid­ ence‐based standards, considered in reaching its decision or, in the case of external reviews of experimental or investigational services or treatments, the written opinion of each clinical re­ viewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer's recommendation; 5. The date of its decisions; 6. The principal reason or reasons for its decision, including what applicable, if any, evidence‐based standards that were a basis for its decision; and 7. The rationale for its decision. Upon receipt of a notice of a decision reversing the Adverse Deter­ mination or Final Adverse Determination, the Plan shall immediately approve the coverage that was the subject of the determination. Bene­ fits will not be provided for services or supplies not covered under the benefit program even if the IRO determines that the health care ser­ vices being reviewed were medically appropriate. The IRO is not bound by any claim determinations reached prior to the submission of information to the IRO. The Director, you, your author­ ized representative, if applicable, and the Plan will receive written notice from the IRO. If you receive an Adverse Determination or a Final Adverse Determination, you may file a a request for an external review within: 4 months after receipt of notice The Plan shall complete a preliminary review of the request within: 5 business days after receiving request if the request is not complete the Plan shall notify you and include what information or materials are required within: one business day after the preliminary review if the request is not eligible for external review the Plan shall notify you and include the reasons for its ineligibility within: one business day after the preliminary review The Plan shall notify you that a request is eligible for external review within: one business day after the preliminary review The Director shall assign an independent review organization (IRO) within: 5 bu...
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IRO's Decision. In addition to the documents and information provided by the Plan and you, or if applicable, your authorized representative, the IRO shall also consider the following information if available and ap­ propriate:
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Related to IRO's Decision

  • Review of Decision Within sixty (60) days after the Secretary’s receipt of a request for review, he or she will review the Company’s determination. After considering all materials presented by the Claimant, the Secretary will render a written opinion, written in a manner calculated to be understood by the Claimant, setting forth the specific reasons for the decision and containing specific references to the pertinent provisions of this Agreement on which the decision is based. If special circumstances require that the sixty (60) day time period be extended, the Secretary will so notify the Claimant and will render the decision as soon as possible, but no later than one hundred twenty (120) days after receipt of the request for review.

  • Claim Decision Upon receipt of such claim, the Plan Administrator shall respond to such claimant within ninety (90) days after receiving the claim. If the Plan Administrator determines that special circumstances require additional time for processing the claim, the Plan Administrator can extend the response period by an additional ninety (90) days for reasonable cause by notifying the claimant in writing, prior to the end of the initial ninety (90) day period, that an additional period is required. The notice of extension must set forth the special circumstances and the date by which the Plan Administrator expects to render its decision. If the claim is denied in whole or in part, the Plan Administrator shall notify the claimant in writing of such denial. The Plan Administrator shall write the notification in a manner calculated to be understood by the claimant. The notification shall set forth: (i) The specific reasons for the denial; (ii) The specific reference to pertinent provisions of the Agreement on which the denial is based; (iii) A description of any additional information or material necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; (iv) Appropriate information as to the steps to be taken if the claimant wishes to submit the claim for review and the time limits applicable to such procedures; and (v) A statement of the claimant’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review.

  • The Decision If mediation fails, or is not appropriate, and if the decision can be rendered after a short deliberation, the Arbitrator will do so. By meeting first with counsel to explain the framework of the Arbitrator’s decision, the parties are provided with an opportunity to influence the exact terms of resolution. Within the framework of settlement as outlined by the Arbitrator, the parties can work out exact terms which best suit the specifics of the case. Such an opportunity should not be wasted by continuing to argue the merits of the case.

  • Arbitration Decision The arbitrator’s decision will be final and binding. The arbitrator shall issue a written arbitration decision revealing the essential findings and conclusions upon which the decision and/or award is based. A party’s right to appeal the decision is limited to grounds provided under applicable federal or state law.

  • Final Decision Concessionaire covenants that the decision of the Commissioner of Department, relative to the performance of the terms and conditions of this Agreement, shall be final and conclusive.