Common use of Preliminary Review Clause in Contracts

Preliminary Review. Upon receipt of a request for standard external review, The Plan must complete a preliminary review within 5 business days to determine whether: a. The Member is or was covered under The Plan when the health care service or treatment was requested or, in the case of a retrospective review, whether the Member was covered under The Plan when the health care service or treatment was provided; b. The requested health care service or treatment that is the subject of the adverse benefit determination or final internal adverse benefit determination: (i) is a covered Benefit under the Member’s health plan except for The Plan’s determination that the health care service or treatment is experimental or investigational for a particular medical condition; and (ii) is not explicitly listed as an excluded Benefit under the Member’s health plan; c. The Member’s treating health care provider has certified that one of the following situations is applicable: (i) standard health care services or treatments have not been effective in improving the condition of the Member; (ii) standard health care services or treatments are not medically appropriate for the Member; or (iii) there is no available standard health care service or treatment covered by The Plan that is more beneficial than the requested health care service or treatment; (i) The Member’s treating health care provider has recommended a health care service or treatment that the Physician certifies, in writing, is likely to be more beneficial to the Member, in the Physician's opinion, than any available standard health care services or treatments; or (ii) a Physician who is licensed, board-certified, or eligible to take the examination to become board-certified and is qualified to practice in the area of medicine appropriate to treat the Member’s condition has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the Member who is subject to the adverse benefit determination or final internal adverse benefit determination is likely to be more beneficial to the Member than any available standard health care services or treatments; and e. The Member has exhausted The Plan’s internal appeals process, or the Member is exempt from exhausting The Plan’s internal appeals process. Within 1 business day after completion of the preliminary review, The Plan will notify the Member or the Member’s authorized representative in writing as to whether the request is complete, and the request is eligible for external review. If the request is not complete, The Plan will inform the Member or the Member’s authorized representative in writing and include in the notice the information or materials that are needed to make the request complete. If the request is not eligible for external review, The Plan will inform the Member or the Member’s authorized representative in writing and include in the notice the reasons for the request's ineligibility. The notice of initial determination will include a statement informing the Member or the Member’s authorized representative of the right to appeal the determination of ineligibility to the Commissioner of Securities and Insurance. The notice will also provide contact information for the Commissioner’s office.

Preliminary Review. Upon Within five business days of receipt of a the request for standard external reviewfrom the Director, The the Plan must will complete a preliminary review within 5 business days of your request to determine whether: a. : • You were an Enrollee at the time health care service was requested or provided; • The Member service that is the subject of the Adverse Determination or was covered the Final Adverse Determination is a Covered Service under The this benefit program, but the Plan when has determined that the health care service is not covered; • You have exhausted the Plan's internal appeal process, unless you are not required to exhaust the Plan's internal appeal process pursuant to the Illinois Health Carrier External Review Act; and • You have provided all the information and forms required to process an external review. For appeals relating to a determination based on treatment being experimental or treatment was requested orinvestigational, in the case of Plan will complete a retrospective review, preliminary review to determine whether the Member was covered under The Plan when the health care service or treatment was provided; b. The requested health care service or treatment that is the subject of the adverse benefit determination Adverse Determination or final internal adverse benefit determination: (i) Final Adverse Determination is a covered Benefit under the Member’s health plan Covered Service, except for The the Plan’s 's determination that the health care service or treatment is experimental or investigational for a particular medical condition; condition and (ii) is not explicitly listed as an excluded Benefit under the Member’s health plan; c. The Member’s treating benefit. In addition, your health care provider Provider has certified that one of the following situations is applicable: (i) standard • Standard health care services or treatments have not been effective in improving the condition of the Memberyour condition; (ii) standard • Standard health care services or treatments are not medically appropriate for the Memberyou; or (iii) there • There is no available standard health care service services or treatment covered by The the Plan that is more beneficial than the recommended or requested health care service or treatment; (i; • In addition, a) The Member’s treating your health care provider Provider has recommended a certified in writing that the health care service or treatment that the Physician certifies, in writing, is likely to be more beneficial to the Memberyou, in the Physician's opinionopinion of your health care Provider, than any available standard health care services or treatments; or (iib) a Physician your health care Provider, who is a licensed, board-certified, board certified or board eligible to take the examination to become board-certified and is Physician qualified to practice in the area of medicine appropriate to treat the Member’s your condition has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the Member who is subject to the adverse benefit determination or final internal adverse benefit determination is likely to be more beneficial to the Member you than any available standard health care services or treatments; and e. The Member has exhausted The Plan’s internal appeals process, or the Member is exempt from exhausting The Plan’s internal appeals process. Within 1 business day after completion of the preliminary review, The Plan will notify the Member or the Member’s authorized representative in writing as to whether the request is complete, and the request is eligible for external review. If the request is not complete, The Plan will inform the Member or the Member’s authorized representative in writing and include in the notice the information or materials that are needed to make the request complete. If the request is not eligible for external review, The Plan will inform the Member or the Member’s authorized representative in writing and include in the notice the reasons for the request's ineligibility. The notice of initial determination will include a statement informing the Member or the Member’s authorized representative of the right to appeal the determination of ineligibility to the Commissioner of Securities and Insurance. The notice will also provide contact information for the Commissioner’s office.

Preliminary Review. Upon receipt of a request for standard external review, The Plan must complete a preliminary review within 5 business days to determine whether: a. The Member is or was covered under The Plan when the health care service or treatment was requested or, in the case of a retrospective review, whether the Member was covered under The Plan when the health care service or treatment was provided; b. The requested health care service or treatment that is the subject of the adverse benefit determination or final internal adverse benefit determination: (i) is a covered Benefit under the Member’s health plan except for The Plan’s determination that the health care service or treatment is experimental or investigational for a particular medical condition; and (ii) is not explicitly listed as an excluded Benefit under the Member’s health plan; c. The Member’s treating health care provider has certified that one of the following situations is applicable: (i) standard health care services or treatments have not been effective in improving the condition of the Member; (ii) standard health care services or treatments are not medically appropriate for the Member; or (iii) there is no available standard health care service or treatment covered by The Plan that is more beneficial than the requested health care service or treatment; (i) The Member’s treating health care provider has recommended a health care service or treatment that the Physician certifies, in writing, is likely to be more beneficial to the Member, in the Physician's opinion, than any available standard health care services or treatments; or (ii) a Physician who is licensed, board-certified, or eligible to take the examination to become board-certified and is qualified to practice in the area of medicine appropriate to treat the Member’s condition has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the Member who is subject to the adverse benefit determination or final internal adverse benefit determination is likely to be more beneficial to the Member than any available standard health care services or treatments; and e. The Member has exhausted The Plan’s internal appeals process, or the Member is exempt from exhausting The Plan’s internal appeals process. 20 Within 1 business day after completion of the preliminary review, The Plan will notify the Member or the Member’s authorized representative in writing as to whether the request is complete, and the request is eligible for external review. If the request is not complete, The Plan will inform the Member or the Member’s authorized representative in writing and include in the notice the information or materials that are needed to make the request complete. If the request is not eligible for external review, The Plan will inform the Member or the Member’s authorized representative in writing and include in the notice the reasons for the request's ineligibility. The notice of initial determination will include a statement informing the Member or the Member’s authorized representative of the right to appeal the determination of ineligibility to the Commissioner of Securities and Insurance. The notice will also provide contact information for the Commissioner’s office.