External Reviewrequestform

EXTERNAL REVIEWREQUESTFORM

ThisExternalReviewRequestFormmustbefiledwiththeVirginiaBureauofInsurancewithin120DAYSafterreceiptfromyourhealthcarrierofadenialofpaymentonaclaimorrequestforcoverageofahealthcareserviceortreatment.

NameofApplicant:

Applicantis:(checkone) Coveredperson/Patient  Provider  AuthorizedRepresentative(NOTE:Form216-Bmustbecompletediftheapplicantisnotthecoveredperson.)

CoveredPersonInformation:

Name:

StreetAddress:

City:State:Zip:

DateofBirth:

Phone:Home ()Work(_)

Fax:()

Email:

InsuranceInformation:

HealthCarrierName:

CoveredPersonInsuranceID#:

InsuranceClaim/Reference#:

HealthCarrierMailingAddress:

HealthCarrierPhone:

EmployerInformation:

Employer’sName:

Employer’sPhone:()

Isthehealthcoverageyouhavethroughyouremployeraself-fundedplan?.

(IfyouarenotcertainpleasecheckwithyourHumanResourceofficeorplanadministrator.)

HealthCareProviderInformation:

TreatingHealthCareProvider(forthedeniedservices):

Address:

ContactPerson:

Phone: ()

ReasonforHealthCarrierDenial(Pleasecheckone):

□Thehealthcareserviceortreatmentdoesnotmeettherequirementsformedicalnecessity,appropriateness,healthcaresetting,levelofcare,oreffectiveness.

□Thehealthcareserviceortreatmentisexperimentalorinvestigational(Form216-Disrequired).(NOTE:Otherreasonsfordenialarenoteligibleforexternalreview.)

SUMMARYOFEXTERNALREVIEWREQUEST(Enterabriefdescriptionofthehealthcareserviceortreatmentthatwasdenied,andattachacopyofthedenialletterfromyourhealthcarrier).

Donotattachmedicalrecordsatthistime.Ifyourappealisdeterminedtobeeligible,youwillbenotifiedwhenandwheretosubmityourmedicalrecordsandotherdocumentationinsupportofyourappeal.

EXPEDITEDREVIEW

Ifyouneedafastdecision,youmayrequestthatyourexternalreviewbehandledonanexpeditedbasis.Youmaynotrequestanexpeditedreviewiftheservicehasalreadybeenprovided.

Hastheservicebeenprovided?Yes

No

To completethis request,your treatinghealthcare providermustcomplete Form 216-Cstating that adelaywouldseriouslyjeopardizethelifeorhealthofthepatientorwouldjeopardizethepatient’sabilitytoregainmaximumfunction.*

Isthisarequestforanexpeditedreview?Yes

No

*Ifyouhavereceivedafinaladversedeterminationinvolvingemergencyservices,andyouhavenotyetbeendischargedfromafacility,checkhere . Form216-Cisnotrequired.

SIGNATUREANDRELEASEOFMEDICALRECORDS

Toappealyourhealthcarrier’sdenial,youmustsignanddatethisexternalreviewrequestformandconsenttothereleaseofmedicalrecords.

I,,herebyrequestanexternalreview.Iattestthattheinformationprovidedinthisapplicationistrueandaccuratetothebestofmyknowledge.Iauthorizethehealthcarrier,anythird-partyadministrator,andthehealthcareproviderstoreleaseallrelevantmedicalortreatmentrecordstotheindependentrevieworganization.Iunderstandthattheindependentrevieworganizationwillusethisinformationtomakeadeterminationonthisexternalreviewandthattheinformationwillbekeptconfidentialandnotbereleasedtoanyoneelse.Thisreleaseisvaliduntiltheexternalreviewiscomplete.

SignatureofCoveredPerson(orlegalrepresentative*)Date

*Parent,Guardian,ConservatororOther–pleasespecify