modelnoticeoffinalexternalreviewdecision-DateofNotice.docVIP

Model Notice of Final External Review Decision – Revised July 3, 2014 PAGE  OMB Control Number 1210-0144 (expires 10/31/2018) Date of Notice Name of Plan Telephone/Fax Address Website/Email Address This document contains important information that you should retain for your records. This document serves as notice of a final external review decision. We have [upheld/overturned/modified] the denial of your request for the provision of, or payment for, a health care service or course of treatment. Historical Case Details: Patient Name:ID Number:Address: (street, county, state, zip)Claim #:Date of Service:Provider:Reason for Denial (in whole or in part): Amt. ChargedAllowed Amt.Other InsuranceDeductibleCo-payCoinsuranceOther Amts. Not CoveredAmt. Paid YTD Credit toward Deductible:YTD Credit toward Out-of-Pocket Maximum:Description of Service: Denial Codes:  [If denial is not related to a specific claim, only name and ID number need to be included in the box. The reason for the denial would need to be clear in the narrative below.] Background Information: Describe facts of the case including type of appeal, date appeal filed, date appeal was received by IRO and date IRO decision was made. Final External Review Decision: State decision. List all documents and statements that were reviewed to make this final external review decision. Findings: Discuss the principal reason or reasons for IRO decision, including the rationale and any evidence-based standards or coverage provisions that were relied on in making this decision. Model Notice of Final External Review Decision – Revised July 3, 2014 PAGE  Important Information about Your Appeal Rights What if I need help understanding this decision? Contact us [insert IRO contact information] if you need assistance understanding this notice. What happens now? If we have overturned the denial, your plan or health insurance issuer will now provide service or paymen