Common use of Standard External Review Clause in Contracts

Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insur­ ance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. Your request should be submitted to the IDOI at the following address: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (877) 850‐4740 Toll‐free phone (217) 557‐8495 Fax number ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇ Email address ▇▇▇▇▇://▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the IDOI will send a copy of the request to the Plan.

Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insur­ ance Insurance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. Your request should be submitted to the IDOI at the following address: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (877▇▇▇) 850‐4740 Toll‐free ▇▇▇-▇▇▇▇ Toll-free phone (217▇▇▇) 557‐8495 ▇▇▇-▇▇▇▇ Fax number ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇ Email address ▇▇▇▇▇://▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the IDOI will send a copy of the request to the Plan.

Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insur­ ance Insurance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. Your request should be submitted to the IDOI at the following address: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (877) 850‐4740 Toll‐free phone Phone number (217) 557‐8495 Fax number ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇ Email address ▇▇▇▇▇://▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Web site address You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the IDOI will send a copy of the request to the Plan.

Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insur­ ance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. Your request should be submitted to the IDOI at the following address: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (877) 850‐4740 Toll‐free phone Phone number (217) 557‐8495 Fax number ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇ Email address ▇▇▇▇▇://▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Web site address You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the IDOI will send a copy of the request to the Plan.

Standard External Review. You or your authorized representative must submit a written request for a standard external independent review to the Illinois Department of Insur­ ance Insurance (“IDOI”) within 4 months of receiving an Adverse Determination or Final Adverse Determination. Your request should be submitted to the IDOI at the following address: Illinois Department of Insurance Office of Consumer Health Insurance External Review Unit ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (877) 850‐4740 Toll‐free 850-4740 Toll-free phone (217▇▇▇) 557‐8495 ▇▇▇-▇▇▇▇ Fax number ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇ Email address ▇▇▇▇▇://▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ You may submit additional information or documentation to support your request for the health care services. Within one business day after the date of receipt of the request, the IDOI will send a copy of the request to the Plan.