Ingeniería de la obra

IMPORTANT NOTICE

YOUR RIGHT TO AN INDEPENDENT MEDICAL REVIEW

If You believe that health care services have been improperly denied, modified, or delayed You may have the right to an independent medical review. For more information about how- to obtain this review, please call KPIC toll free number at 1-888-865-5813.

After We have rendered a final adverse determination upon Your completing our internal appeals process, as described above, You may have a right to request an independent external review of Our final adverse determination.

You have the right to an independent external review upon any of the following:

1. Your membership was terminated retroactively for a reason other than a failure to pay premiums or contributions toward the cost of coverage.

2. If we continue to deny the payment, coverage or service requested.

If Your coverage is through an employer group subject to the Employee Retirement Security Income Act of 1974 (ERISA), You may also have the right to bring a civil action under section 502(a) of ERISA, as then constituted or later amended. To determine if Your plan is covered by ERISA, please check with Your employer.

Experimental or Investigational Therapy

You may also have the right to an independent medical review upon the concurrence of the following: 1. A proposed treatment, drug, device, procedure or therapy is excluded as a Covered Service

under this Group Policy as being experimental;

2. You have a Terminal Condition, duly certified by Your Physician, that:

a. standard therapies have not been effective in improving Your condition; or

b. such standard therapies would be of substantially lesser or of no benefit to You; or

c. there is no other beneficial therapy covered under this Group Policy other than the proposed experimental or investigational therapy; and

d. Your contracting Physician has certified in writing that the recommended treatment, drug, device, procedure or therapy is likely to be more beneficial than any available standard therapy; or

e. Your Physician duly licensed and board certified to practice in the area of practice appropriate for Your condition, has certified in writing that based on medical and scientific evidence, as published in peer reviewed literature, the recommended treatment is likely to be more beneficial to You than any other available standard therapy; and

f. The recommended treatment would otherwise be covered under the Group Policy were it not determined by us that such treatment, drug, device or procedure is experimental or investigational.

NOTE: Experimental drugs that are used to treat cancer are covered under the Prescription Drug Benefit coverage if one or more of the following conditions is met:

1) The drug is recognized for treatment of the Covered Person’s particular type of cancer in the United States Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations or The American Hospital Formulary Service Drug Information publication; or

INDEPENDENT EXTERNAL REVIEW PROCESS

2) The drug is recommended for treatment of the Covered Person’s particular type of cancer and has been found to be safe and effective in formal clinical studies, the results of which have been published in either the United States or Great Britain;

For the purpose of this Section of the Certificate, the following definitions apply:

"Life-threatening" means either or both of the following:

1) Sickness or Injury where the likelihood of death is high unless the course of the Sickness is interrupted.

2) Sickness or Injury with potentially fatal outcomes, where the end point of clinical intervention is survival.

"Seriously Debilitating Condition" means Sickness or Injury that causes major irreversible morbidity.

“Terminal Condition” means a condition, as certified by Your Physician that:

1) Has a substantial probability of causing death within two years from the date of the request for an independent medical review; or

2) Your ability to regain or maintain maximum function would be impaired.

External Review

If You are dissatisfied with our final internal adverse benefit determination regarding Your appeal, You or Your authorized representative may have the right to request an external review by an independent third party organization. Within four (4) months after the date on which You receive our final internal adverse benefit determination, send Your written request for external review to:

Federal External Reviewer U.S. Office of Personnel Management

P.O. Box 791 Washington, D.C. 20044.

Or You may fax Your request to 202-606-0036 or send it electronically to [email protected]. You will not be required to bear the costs of the External Review. You will be provided a Privacy Act Statement and the Release of Information form that must accompany Your written request for external review, as well as a copy of our decision letter. If You need copies of any of these forms or our letter, please contact 1-888-865-5813. If You have any questions or concerns on the external review process, You may call toll free 1-877-549-8152.

You may submit additional information to the external reviewer by sending it to the mailing address for the Federal External Review set forth above. Please note that any additional information that You submit will be shared with us so that we may reconsider our final internal adverse benefit determination.

The federal external reviewer will first determine whether You are entitled to external review and will notify You and Us in writing if You are not eligible for external appeal. The federal external reviewer will then review all of the information and documents timely received de novo and will provide written notice of a final external review decision as soon as possible and no later than 45 days after the federal external reviewer receives Your request for external review. This written notice will be sent to You and Us.

You may make a written or oral request for an expedited external review if (1) the time frame for completion of an expedited internal appeal would seriously jeopardize Your life or health or would jeopardize the claimant’s ability to regain maximum function but only when You have also filed a timely request for an expedited internal appeal related to Your urgent pre-service or concurrent care claim, or (2) You have received our final internal adverse benefit determination and You have a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize the Your

INDEPENDENT EXTERNAL REVIEW PROCESS

life or health or if the final internal adverse benefit determination concerns an admission, availability of care, continued state or health care supply or service for which You have received services, but have not been discharged from a facility.

If the external reviewer determines that You are not eligible for expedited external review, then the external reviewer will notify You and Us as soon as possible. The external reviewer must provide notice of the final expedited external review decision as soon as the medical circumstances require but no later than 72 hours after the external review receives Your request for expedited external review unless You are in an ongoing course of treatment for that condition and then the external review decision will be provided within 24 hours. This notice may be provided orally but must be followed in writing to You and us within 48 hours of the oral notification.

If the external reviewer overturns our decision, we will provide coverage or payment for Your health care service or supply as directed.

Except when external review is permitted to occur simultaneously with internal Appeal, You must exhaust Our internal claims and Appeals procedure for Your Claim before You may request external review unless We have failed to comply with federal requirements regarding Our Claims and Appeals procedures.

You may have certain additional rights if You remain dissatisfied after You have exhausted all levels of review including external review. If You are enrolled through a plan that is subject to the Employee Retirement Income Security Act (ERISA), You may file a civil action under section 502(a) of the federal ERISA statute. To understand these rights, You should check with Your benefits office or contact the Employee Benefits Security Administration (part of the U.S. Department of Labor) at 1-866-444-EBSA (3272). Alternatively, if Your plan is not subject to ERISA (for example, most state or local government plans and church plans or all individual plans), You may have a right to request review in state court.