104 The External Review Process Works as Follows: If your appeal of a claim is denied, whether it’s a pre-service, post-service, or urgent care claim, you may request further review by an Independent Review Organization (IRO) as described below. You may only request external review after you have exhausted the internal review and appeals process described above. NOTE: External review is only available for the following types of claim denials : • A denial that involves medical judgment, including, but not limited to, those based on the Plan’s requirements for Medical Necessity, appropriateness, health care setting, level of care or effectiveness of a covered benefit, or a determination that a treatment is experimental or investigational. The IRO will determine whether a denial involves a medical judgment; and • A denial due to a rescission of coverage (retroactive elimination of coverage), regardless of whether the rescission has any effect on any particular benefit at that time. External review is not available for any other types of denials, including if your claim was denied due to your failure to meet the requirements for eligibility under the terms of the Plan. Under limited circumstances, you may be able to seek external review before the internal claims and appeals process has been completed: • If the Plan waives the requirement that you complete its internal claims and appeals process first. • In an urgent care situation (see “Expedited External Review of Claims”). Generally, an urgent care situation is one in which your health may be in serious jeopardy, or, in the opinion of your health care professional, you may experience pain that cannot be adequately controlled while you wait for a decision on your internal appeal. • If the Plan has not followed its own internal claims and appeals process and the failure was more than a minor error. In this situation, the internal claims and appeal is “deemed exhausted,” and you may proceed to external review. If you think that this situation exists, and the Plan disagrees, you may request that the Plan explain in writing why you are not entitled to seek external review at this time. Your request for external review of a denial must be made, in writing, within four (4) calendar months of the date that you receive the denial. Because the Plan’s internal review and appeals process generally must be exhausted before external review is available, typically external review of claims will only be available for denials of appeals (and not initial claim denials). 1. Preliminary Review a. Within five (5) business days of the Plan’s receipt of your external review request for a claim, the Plan will complete a preliminary review of the request to determine whether: • You are/were covered under the Plan at the time the health care item or service is/was requested or, in the case of a retrospective review, were covered under the Plan at the time the health care item or service was provided; • The denial does not relate to your failure to meet the requirements for eligibility under the terms of the Plan; • You have exhausted the Plan’s internal claims and appeals process (except, in limited, exceptional circumstances); and