Standard External Review. The Insured may submit a request for an External Review of an adverse determination under this section only after • the Insured has exhausted all applicable internal SHLAppeals Procedures provided under this Plan or • if SHL fails to issue a written decision to the Insured within thirty (30) days after the date the Appeal was filed, and the Insured or Insured’s Authorized Representative did not request or agree to a delay or, • if SHL agrees to permit the Insured to submit the adverse determination to OCHA without requiring the Insured to exhaust all internal applicable SHLAppeals Procedures. In such event, the Insured shall be considered to have exhausted the internal SHL Appeals Process. Within five (5) days after OCHA receives a request for External Review, OCHA shall notify the Insured, the Insured’s Authorized Representative and SHLthat such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: • Any medical records of the Insured relating to the adverse determination; • A copy of the provisions of the healthcare Plan upon which the adverse determination was based; • Any documents used and the reason(s) given by SHL’s Managed Care Programfor the adverse determination; and
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Standard External Review. The Insured may submit a request for an External Review of an adverse determination under this section only after • the Insured has exhausted all applicable internal SHLAppeals SHL Appeals Procedures provided under this Plan or • if SHL fails to issue a written decision to the Insured within thirty (30) days after the date the Appeal was filed, and the Insured or Insured’s Authorized Representative did not request or agree to a delay or, • if SHL agrees to permit the Insured to submit the adverse determination to OCHA without requiring the Insured to exhaust all internal applicable SHLAppeals SHL Appeals Procedures. In such event, the Insured shall be considered to have exhausted the internal SHL Appeals Process. Within five (5) days after OCHA ▇▇▇▇ receives a request for External Review, OCHA shall notify the Insured, the Insured’s Authorized Representative and SHLthat SHL that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the case. Within five (5) days after receiving notification specifying the assigned IRO from OCHA, SHL shall provide to the selected IRO all documents and materials relating to the adverse determination, including, without limitation: • Any medical records of the Insured relating to the adverse determination; • A copy of the provisions of the healthcare Plan upon which the adverse determination was based; • Any documents used and the reason(s) given by SHL’s Managed Care Programfor Program for the adverse determination; and
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