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Adverse determinations will only be made by a clinical peer reviewer of AHP when requested health services or a level of care are denied because they fail to meet the established written utilization review criteria of the plan for medical necessity and appropriateness of the level of care.

A clinical peer reviewer is a physician who possesses a current and valid non-restricted license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current and valid non-restricted license, certification or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession and is in the same profession/specialty as the health care provider who typically manages the medical condition.

Notices of adverse determination are made in writing and include:

• the reasons for the determination
• the clinical rationale, if any,
• instructions on how to initiate an appeal
• notice of availability of the clinical review criteria upon which the determination was based, upon request of the member or the member�s designee,
• specification of any additional information which should be provided to, or obtained by the plan in order to render a decision on the appeal.

You, your designee, or your health care provider may request from AHP a reconsideration or appeal of the adverse determination. Various types of appeals and time frames for responses are provided for, depending on the following circumstances under which the adverse determination was made:

• reconsideration within one (1) business day of receipt of the request;
• expedited appeal with access to a clinical peer reviewer within one (1) business day and a determination completed in two (2) business days of receipt of necessary information to conduct the appeal.
• standard appeal with a determination completed within sixty (60) days of receipt of necessary information to conduct the appeal. AHP will issue written notification of the appeal determination within two (2) business days.
• retrospective review determination is made within thirty (30) days of receipt of necessary information with which to render the decision.

INTERNAL APPEAL PROCEDURES

1. Except in cases of adverse determinations made during retrospective review, when an adverse determination is made without attempting to discuss the plan of care with the health care provider who specifically recommended the health care service, procedure or treatment under review, the provider may request a reconsideration of the adverse determination.

   Reconsideration will occur within one (1) business day of receipt of the request, and will be conducted between the member�s health care provider and the clinical peer reviewer who made the initial determination (or a designated substitute if the original reviewer is not available).

   If the adverse determination is upheld after reconsideration, AHP will issue a written notice of adverse determination within one (1) business day after the determination. The member or the member�s designee or the member�s health care provider may then proceed to further appeal the decision using either the expedited appeal or the standard appeal, as defined below.

2. Except in cases of adverse determinations made during retrospective review, an Expedited Appeal is allowed in situations involving:
   1. continued or extended health care services, procedures or treatments or additional services for a member undergoing a course of continued treatment prescribed by a health care provider;
   2. the health care provider believes an immediate appeal is warranted.

   AHP will provide the member�s health care provider with reasonable access within one (1) business day of receiving notice of the taking of an expedited appeal, to a clinical peer reviewer other than the clinical peer reviewer who rendered the adverse determination.

   The clinical peer reviewer will render a determination within two (2) business days of receipt of necessary information to conduct the appeal.

   Expedited appeals, which do not result in a resolution satisfactory to the appealing party, may be further appealed through the standard appeal process, as defined below, or a request can be made for an external appeal (refer to page 21 External Appeal Procedure)

3. Except in cases of adverse determinations made during retrospective review, a Standard Appeal process is required in all other situations than those described above.

   These appeals may be filed in writing or by telephone. To file a standard appeal of an adverse determination, an appealing party has no less than forty-five (45) days after the member receives a notice of adverse determination and AHP receives all necessary information to conduct the appeal.

   AHP will send written acknowledgment of receipt of the appeal to the appealing party within fifteen (15) days of the date of the appeal. AHP will assign a clinical peer reviewer other than the one who rendered the adverse determination, and the appeal determination will be rendered within sixty (60) days of receipt of information necessary to conduct the appeal.

   Thereafter, AHP will issue written notification of the appeal determination within two (2) business days to the member, the member�s designee and the member�s health care provider. This notice will include reasons for the determination, with the clinical rationale provided where the adverse determination is upheld on the appeal.

4. Retrospective review determinations involve services, which have already been delivered to the member. An appeal or reconsideration of adverse determinations of this type will comply with the procedures of the standard appeal except that the appeal determination must be made within thirty (30) days of receipt of information necessary to conduct the appeal. AHP will assign a clinical peer reviewer other than the one who rendered the adverse determination.

You may file an application for an external appeal by a state approved external appeal agent if you have received a denial of coverage based on medical necessity or because the service is experimental and/or investigational.

To be eligible for an external appeal, you must have received a final adverse determination as a result of AHP�s first-level utilization review (UR) appeal process or both you and AHP must jointly agree to waive the UR appeal process.

You may obtain an external appeal application from:

• The New York State Department of Insurance at 1-800-400-8882, or its website
  (www.ins.state.ny.us),
• The New York State Department of Health website only
  (www.health.state.ny.us) or
• Our Member Services Department at 1-877-MD-ASSIST.

The application will provide clear instructions for completion. To file an external appeal, you must include $50.00 with the application. This money will be refunded if the external appeal is decided in your favor. You may obtain a waiver of this fee if you meet AHP�s criteria for a hardship exemption.

The application for external appeal must be made within 45 days of your receipt of the notice of final adverse determination as a result of AHP�s first-level appeal process, or within 45 days of when you and AHP jointly agree to waive the internal appeal process. Additional internal AHP appeals are available to you which are optional.

However, regardless of whether you participate in additional AHP internal appeals, an application for external appeal must be filed with the New York State Department of Insurance within 45 days from your receipt of the notice of final adverse determination from AHP�s first-level appeal to be eligible to be reviewed by an external appeal agent.

You will lose your right to an external appeal if you do not file an application for an external appeal within 45 days from your receipt of the final adverse determination from the first level internal plan appeal.

An external appeal agent must decide a standard appeal within 30 days of receiving your application for external appeal from the state. Five (5) additional business days may be added if the agent needs additional information. If the agent determines that the information submitted to it is materially different from that considered by AHP, AHP will have three (3) additional business days to reconsider or affirm its decision. You and AHP will be notified within 2 business days of the agent�s decision.

You may request an expedited appeal if your doctor can attest that a delay in providing the recommended treatment would pose an imminent or serious threat to your health. The external appeal agent will make a decision within three days for expedited appeals. Every reasonable effort will be made to notify you and AHP of the decision by telephone or fax immediately. This will be followed immediately by a written notice.

In the event an adverse determination is overturned on external appeal, or in the event that AHP reverses a denial which is the subject of external appeal, AHP shall provide or arrange to provide the health care service(s) which is the basis of the external appeal to you.

If you are no longer insured by AHP at the time of an external appeal agent�s reversal of AHP�s utilization review denial, AHP will not be required to provide any health care services to you.

You, your designee or your health care provider, may request an external appeal of a retrospective adverse determination if the services in question were denied based on medical necessity and/or were considered experimental and/or investigational.

To request an application for an external appeal, you, your designee, or your health care provider may contact AHP at 1-866-747-8422. AHP will send you, your designee, or your health care provider the application within three (3) business days from the date we receive his/her request for the application. The application will provide clear instructions for completion. To file an external appeal, he/she must include $50.00 with the application. This money will be refunded if the external appeal agent overturns AHP�s adverse determination. Your health care provider may not charge you, the member for this fee.

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