Noblesville Schools Medical Plan 79 Section 6: Questions, Complaints and Appeals Urgent Appeals that Require Immediate Action Your appeal may require urgent action if a delay in treatment could increase the risk to your health, or the ability to regain maximum function, or cause severe pain. In these urgent situations: • The appeal does not need to be submitted in writing. You or your Physician should call the Claims Administrator as soon as possible. • The Claims Administrator will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination, taking into account the seriousness of your condition. • If the Claims Administrator needs more information from your Physician to make a decision, the Claims Administrator will notify you of the decision by the end of the next business day following receipt of the required information. The appeal process for urgent situations does not apply to prescheduled treatments, therapies or surgeries. External Review Program You may be entitled to request an external review of the Claims Administrator's determination after exhausting your internal appeals if either of the following apply: • You are not satisfied with the determination made by the Claims Administrator. • The Claims Administrator fails to respond to your appeal within the timeframe required by the applicable regulations. If one of the above conditions is met, you may request an external review of adverse benefit determinations based upon any of the following: • Clinical reasons. • The exclusions for Experimental or Investigational Service(s) or Unproven Service(s). • Rescission of coverage (coverage that was cancelled or discontinued retroactively). • As otherwise required by applicable law. You or your representative may request a standard external review by sending a written request to the address listed in the determination letter. You or your representative may request an expedited external review, in urgent situations as defined below, by contacting the Claims Administrator at the telephone number on your ID card or by sending a written request to the address listed in the determination letter. A request must be made within four months after the date you received the Claims Administrator's final appeal decision. An external review request should include all of the following: • A specific request for an external review. • Your name, address, and insurance ID number. • Your designated representative's name and address, when applicable. • The service that was denied. • Any new, relevant information that was not provided during the internal appeal. An external review will be performed by an Independent Review Organization (IRO). The Claims Administrator has entered into agreements with three or more IROs that have agreed to perform such reviews. There are two types of external reviews available: