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We must issue a written decision to you and, if applicable, to your representative or provider, within 10 business <br />days after completing the review meeting. The decision must include: <br />(1) the name(s), title(s) and qualifying credentials of the members of the review panel; <br />(2) a statement of the review panel's understanding of the nature of the Grievance and all pertinent facts; <br />(3) the review panel's recommendation to the Company and the rationale behind the recommendation; <br />(4) a description of, or reference to, the evidence or documentation considered by the review panel in <br />making the recommendation; <br />(5) In the review of a Utilization Review non -certification or other clinical matter, a written statement of the <br />clinical rationale, including the clinical review criteria, that was used by the review panel to make the <br />determination; <br />(6) the rationale for the Company's decision if it differs from the review panel's recommendation; <br />(7) a statement that the decision is the Company's final determination in the matter; <br />(8) notice of the availability of the Commissioner's office for assistance, including the telephone number <br />and address of the Commissioner's office. <br />EXPEDITED REVIEW <br />Youareeligible for an expedited review -when the timeframes for an Informal, formal First Level review or Second <br />Level review would reasonably appear to seriously jeopardize your life or health, or your ability to regain maximum <br />function. An expedited review is also available for all Grievances concerning an admission, availability of care, <br />continued stay or health care service for a person who has received emergency services, but who has not been <br />discharged from a facility. <br />A request for an expedited review may be submitted orally or in writing. An expedited review must be evaluated by <br />an appropriate clinical peer in the same or similar specialty as would typically manage the case being reviewed. If <br />we don't have the information necessary to decide an appeal, we will send you notification of precisely what is <br />required within 24-hours of our receipt of your Grievance. All necessary information, including our decision, will be <br />transmitted by telephone, facsimile, or the most expeditious method available. Provided we have enough <br />information to make a decision, you, your authorized representative, or a provider acting on your behalf will be <br />notified of the determination as expeditiously as the medical condition requires, but in no event more than 72-hours <br />after the review. has commenced. Written confirmation of our decision will be provided within 2 working business <br />days of the decision and will contain the same items described in the written decision requirements for First Level <br />reviews. <br />If the expedited review does not resolve the situation, you, your representative or a provider acting on your behalf <br />may submit a written Grievance. <br />We will not provide an expedited review for retrospective reviews of Adverse Determinations <br />Grievance <br />