Reso 2010-1529 - Laserfiche WebLink

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') o ) Determination, without regard to whether the advice was relied upon in making the Adverse Benefit Determination. 16.07.07 The appeal shall provide that the Health Professional engaged for purposes ofa consultation in Subsection 16.07.05 shall be an individual who is neither an individual who was consulted in connection with the initial Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of any such individual. 16.07.08 In the case of an Urgent Care Claim, there shall be an expedited review process pursuant to which: a) Request for an expedited appeal of an Adverse Benefit Determination may be submitted orally or in writing by the Claimant; and b) All necessary information, including AvMed's benefit determination on review, shall be transmitted between AvMed and the Claimant by telephone, facsimile, or other available similarly expeditious methods. 16.08 Manner and content of appeal notification. AvMed shall provide a Claimant with written or electronic notification ofAvMed's benefit determination upon review. 16.08.0] In the case of an Adverse Benefit Determination, the notification shall set forth, in a manner calculated to be understood by the Claimant, all of the following, as appropriate: a) The specific reasons for the Adverse Benefit Determination. b) Reference to the specific Plan provisions on which the Adverse Benefit Determination is based. c) A statement that the Clairnant is entitled to receive, upon request, and free of charge, reasonable access to, and copies of any Relevant Documents. ) d) A statement describing any voluntary appeal procedures offered by AvMed and the Claimant's right to obtain the information about such procedures and a statement of the Claimant's right to bring an action under ERISA Section 502(a) when applicable. e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making tbe Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in rnaking the Adverse Benefit Determination and that a copy shall be provided free of charge.to the Claimant upon request. f) If the Adverse Benefit Determination is based on whether the treatment or service is experimental and/or investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant's rnedical circumstances, or a statement that such explanation shall be provided free of charge upon request. XVII. MISCELLANEOUS 17.0 I Applicability of law. The provisions of this Contract shall be deemed to have been modified by the parties, and shall be interpreted, so as to comply with the Jaws and regulations of the State of Florida and the United States. 44 A V -0100-2009 MP-5319 (]0/09)