105 • You have provided all of the information and forms required to process an external review. b. Within one business day of completing its preliminary review, the Plan will notify you in writing as to whether your request meets the threshold requirements for external review. If applicable, this notification will inform you: • If your request is complete and eligible for external review, or • If your request is complete but not eligible for external review, in which case the notice will include the reasons for its ineligibility, and contact information for the Employee Benefits Security Administration (toll-free number (866) 444-EBSA (3272)), or • If your request is not complete, in which case the notice will describe the information or materials needed to make the request complete, and allow you to perfect the request for external review within the four-month filing period, or within a 48-hour period following receipt of the notification, whichever is later. 2. Review by Independent Review Organization If the request is complete and eligible, the Plan will assign the request to an Independent Review Organization or “IRO.” The IRO is not eligible for any financial incentive or payment based on the likelihood that the IRO would support the denial of benefits. The Plan has contracted with more than one IRO and generally rotates assignment of external reviews among the IROs with which it contracts. Once the claim is assigned to an IRO, the following procedure will apply: • The assigned IRO will timely notify you in writing of the request’s eligibility and acceptance for external review, including directions about how you may submit additional information regarding your claim (generally, such information must be submitted within ten (10) business days). • Within five (5) business days after the assignment to the IRO, the Plan will provide the IRO with the documents and information it considered in making its denial determination. • If you submit additional information related to your claim, the assigned IRO must within one business day forward that information to the Plan. Upon receipt of any such information, the Plan may reconsider its denial that is the subject of the external review. Reconsideration by the Plan will not delay the external review. However, if upon reconsideration, the Plan reverses its denial, it will provide written notice of its decision to you and the IRO within one business day after making that decision. Upon receipt of such notice, the IRO will terminate its external review. • The IRO will review all of the information and documents timely received. In reaching a decision, the IRO will review the claim de novo (as if it is new) and will not be bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to observe the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. The IRO also must observe the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit. In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and appropriate, may consider additional information, including information from your medical records, any recommendations or other information from your treating health care providers, any other information from you or the Plan, reports from appropriate health care professionals, appropriate practice guidelines, the Plan’s applicable clinical review criteria and/or the opinion of the IRO’s clinical reviewer(s), unless such requirements are inconsistent with applicable law.