Part 4 – Utilization Review Requirements (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 29 your coverage in this health plan; the specific medical and scientific reasons for which Blue Cross Blue Shield HMO Blue has denied the request; any alternative treatment or health care services and supplies that would be covered; Blue Cross Blue Shield HMO Blue clinical guidelines that apply and were used and any review criteria; and the review process and your right to pursue legal action. Reconsideration of Adverse Determination Your health care provider may ask that Blue Cross Blue Shield HMO Blue reconsider its decision when Blue Cross Blue Shield HMO Blue has determined that your proposed health care service, supply, or course of treatment is not medically necessary for your condition. In this case, Blue Cross Blue Shield HMO Blue will arrange for the decision to be reviewed by a clinical peer reviewer. This review will be held between your health care provider and the clinical peer reviewer. And, it will be held within one working day of the date that your health care provider asks for Blue Cross Blue Shield HMO Blue’s decision to be reconsidered. If the initial decision is not reversed, you (or the health care provider on your behalf) may ask for a formal review. The process to ask for a formal review is described in Part 10 of this Subscriber Certificate. You may request a formal review even if your health care provider has not asked that the Blue Cross Blue Shield HMO Blue decision be reconsidered. Pre-Admission Review Before you go into a hospital or other covered health care facility for inpatient care, your health care provider must obtain an approval from Blue Cross Blue Shield HMO Blue in order for your care to be covered by this health plan. (This does not apply to your admission if it is for emergency medical care or for maternity care.) Blue Cross Blue Shield HMO Blue will determine if the health care setting is suitable to treat your condition. Blue Cross Blue Shield HMO Blue will make this decision within two working days of the date that it receives all of the needed information from your health care provider. Any pre- admission review approval from Blue Cross Blue Shield HMO Blue applies to your inpatient admission only. There may be certain health care services or supplies that are furnished during your admission that also require pre-service approval from Blue Cross Blue Shield HMO Blue. See “Pre-Service Approval Requirements” above in this section. Exception: If your admission is for substance use treatment in a hospital or other covered health care facility that is certified or licensed by the Massachusetts Department of Public Health, prior approval from Blue Cross Blue Shield HMO Blue will not be required. For an admission in one of these health care facilities, coverage will be provided for medically necessary acute treatment services and clinical stabilization services for up to a total of 14 days without prior approval, as long as the health care facility notifies Blue Cross Blue Shield HMO Blue and provides the initial treatment plan within 48 hours of your admission. Concurrent Review (see page 30) will start on or after day seven of your admission. For all other admissions (except as described in the paragraph above), you must have prior approval from Blue Cross Blue Shield HMO Blue in order for your inpatient care to be covered by this health plan. Missing Information In some cases, Blue Cross Blue Shield HMO Blue will need more information or records to determine if the health care setting is suitable to treat your condition. For example, Blue Cross Blue Shield HMO Blue may ask for the results of a face-to-face clinical evaluation or of a second opinion. If Blue Cross Blue Shield HMO Blue does need more information, Blue Cross Blue Shield HMO Blue will ask for this missing information or records within 15 calendar days of the date that it received your health care provider’s request for approval. The information or records that Blue Cross Blue Shield HMO Blue asks for must be provided to Blue Cross Blue Shield HMO Blue within 45 calendar days of the request. If this information or these records are not provided to Blue Cross Blue Shield HMO Blue within these 45 calendar days, your proposed coverage will be denied. If Blue Cross Blue Shield HMO Blue receives