Part 10 – Appeal and Grievance Program (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 91 Expedited Review for Immediate or Urgently-Needed Services In place of the internal formal review as described above in this section, you have the right to request an “expedited” review right away when your situation is for immediate or urgently-needed services. Blue Cross Blue Shield HMO Blue will respond to formal requests for a review for immediate or urgently-needed services as follows:  When your request for a review concerns medical care or treatment for which waiting for a response under the review time frames described above would seriously jeopardize your life or health or your ability to regain maximum function as determined by Blue Cross Blue Shield HMO Blue or your physician, or if your physician says that you will have severe pain that cannot be adequately managed without the care or treatment that is the subject of the review, Blue Cross Blue Shield HMO Blue will review your request and notify you of the decision within 72 hours after your request is received, or such shorter time period as required by federal law.  When a formal review is requested while you are an inpatient, Blue Cross Blue Shield HMO Blue will complete the review and make a decision regarding the request before you are discharged from that inpatient stay.  Blue Cross Blue Shield HMO Blue’s decision to deny payment for health care services, including durable medical equipment, may be reversed within 48 hours if your attending physician certifies to Blue Cross Blue Shield HMO Blue that a denial for those health care services would create a substantial risk of serious harm to you if you were to wait for the outcome of the normal formal review process. Your physician can also request the reversal of a denial for durable medical equipment earlier than 48 hours by providing more specific information to Blue Cross Blue Shield HMO Blue about the immediate and severe harm to you.  A formal review requested by a member with a terminal illness will be completed by Blue Cross Blue Shield HMO Blue within five working days of receiving the request. In this case, if the expedited review results in a denial for health care services or treatment, Blue Cross Blue Shield HMO Blue will send a letter to the member within five working days. This letter will include: information related to the details of the request for a review; the reasons that Blue Cross Blue Shield HMO Blue has denied the request and the applicable terms of 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 how to request a hearing. When the member requests a hearing, the hearing will be held within ten days. (Or, it will be held within five working days if the attending physician determines after consultation with Blue Cross Blue Shield HMO Blue’s Medical Director and based on standard medical practice that the effectiveness of the health care service, supply, or treatment would be materially reduced if it were not furnished at the earliest possible date.) You and/or your authorized or legal representative(s) may attend this hearing. External Review You must first go through the Blue Cross Blue Shield HMO Blue internal formal appeal and grievance review process as described above, unless Blue Cross Blue Shield HMO Blue has failed to comply with the time frames for the internal formal review or if you (or your authorized or legal representative) are requesting an expedited external review at the same time you (or your authorized or legal representative) are requesting an expedited internal review. The Blue Cross Blue Shield HMO Blue internal formal review decision may be to continue to deny all or part of your coverage in this health plan. When you are denied coverage for a service or supply because Blue Cross Blue Shield HMO Blue has determined that the service or supply is not medically necessary, you have the right to an external review. You are not required to pursue an external review. Your decision whether to pursue an external review will not affect your other coverage. If you receive a denial letter from Blue Cross Blue Shield HMO Blue in response to your internal formal review, the letter will tell you what steps you can take to file a request for an external