Appendix A

Putnam/Northern Westchester Health Benefits Consortium
Appendix A

Utilization Review
This Appendix provides additional information about the Plan's Utilization Review (UR) program and your right to appeal adverse decisions. Utilization Review decisions concern the medical necessity of care and the appropriateness of the provider or level of care. In addition, UR decisions may address experimental and/or investigational procedures.

The Utilization review program follows the below listed steps:

1. Pre-Certification Process

a. All requests for pre-certification of hospital admissions or other services, as required pursuant to the MANAGED BENEFITS PROGRAM beginning on page 38, are reviewed to determine medical necessity (including the appropriateness of the proposed level of care and/or provider) and to determine whether the care is experimental and/or investigational. The initial review is performed by a nurse. If the nurse determines that the proposed care is medically necessary and not experimental and/or investigational, the nurse will authorize the care. (Authorized care is still subject to all benefit
provisions such as deductibles, coinsurance/co-payments and annual/lifetime limitations.)

If the nurse determines that the proposed care is not medically necessary or is experimental and/or investigational; or that further evaluation is needed, the nurse will refer the case to a clinical peer reviewer (a physician who possesses a current and valid non-restricted license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current and valid non-restricted license, certification or registration or, where no provision for a license, certification or registration exists, is credentialled by the national accrediting body appropriate to the
profession and is in the same profession/specialty as the health care provider who typically manages the medical condition). Failure to make a determination within the time periods required by Article 49 of the New York Insurance law will be deemed to be an adverse determination that is subject to an INTERNAL APPEAL.

b. Notice of an approval of proposed care or an adverse determination that proposed care is not medically necessary or is experimental and/or investigational will be provided to you or your authorized designee, and your provider, by telephone and in writing, within 3 business days following receipt of all information necessary to make the decision.

c. The notice of any adverse determination will include the reasons, including clinical rationale, for our determination. The notice will also advise you of your right to a review of the adverse determination, give instructions for initiating standard, expedited and external appeals, and specify that you may request a copy of the clinical review criteria used to make the adverse determination. The notice will also specify additional information or documentation, if any, needed for us to make a Level One internal
appeal determination.

d. If, prior to making an adverse determination, no attempt was made to consult with the provider who requested the prior authorization, the provider may request reconsideration by the same clinical peer reviewer who made the adverse determination. The reconsideration will take place within 1 business day of the request for reconsideration, in consultation with the requesting provider. If the adverse
determination is upheld, notice will be given to the provider, by telephone and in writing, within 3 business days from the date of reconsideration. All of the information described in paragraph 1.c. above will be included in this notice.

2. Concurrent review process.

a. When you are receiving services that are subject to concurrent review, a nurse will periodically assess the medical necessity, level of care, and experimental and/or investigational nature of services you receive throughout the course of treatment.

b. Once a case is assigned for concurrent review, a nurse will determine whether the services being received are medically necessary, at the appropriate level and not experimental and/or investigational. If so, the nurse will authorize the care. If the nurse determines that the care is not medically necessary or is experimental and/or investigational; or that further evaluation is needed; the nurse will refer the case to a clinical peer reviewer (defined in paragraph 1.a. above). Failure to make a etermination
within the time periods required by Article 49 of the New York Insurance Law will be deemed to be an adverse determination that is subject to Level One internal appeal (described in paragraph 4. below).

c. Your provider will be notified of the concurrent review decision, by telephone and in writing, within 1 business day following our receipt of all information or documentation needed for the review.

d. If care is authorized, the notice will identify the number of approved services, the new total of approved services, the date services may begin, and the date of the next scheduled concurrent review of the case. If care is not authorized, the notice of any adverse determination will include the reasons, including clinical rationale, for our determination. The notice will advise you of your right to a review of the adverse determination, give instructions for initiating standard, expedited, and external appeals,
and specify that you may request a copy of the clinical review criteria used to make the adverse determination. The notice will also specify additional information or documentation needed, if any, for us to make a Level One internal appeal determination.

e. If, prior to making an adverse determination, no attempt was made to consult with the provider who requested the prior authorization, the provider may request reconsideration by the same clinical peer reviewer who made the adverse determination. The reconsideration will take place within 1 business day of the request for reconsideration, in consultation with the requesting provider. If the adverse
determination is upheld, notice will be given to the provider, by telephone and in writing, within 1 business day from the date of reconsideration. All of the information described in paragraph 2.d. above will be included in this notice.

3. Retrospective review process.

a. At Aetna’s option, a nurse will review retrospectively the medical necessity and the experimental and/or investigational nature of services, which are subject to utilization review. If the nurse determines that care you received was medically necessary and not experimental and/or investigational, the nurse will authorize benefits. If the nurse determines that the care was not medically necessary or was experimental and/or investigational, the nurse will refer the case to a clinical peer reviewer (defined in
paragraph 1.a. above). Failure to make a determination within the time periods required by Article 49 of the New York Insurance Law will be deemed to be an adverse determination that is subject to Level One internal appeal (described in paragraph 4. below).

b. You or your authorized designee and your provider will be notified of the retrospective review determination, in writing, within 30 calendar days from our receipt of all information or documentation needed for the review.

c. The notice of any adverse determination will include the reasons, including clinical rationale, for our determination. The notice will advise you of your right to request a review of the adverse determination, give instructions for initiating standard, expedited, or external appeals, and specify that you or your authorized designee may request a copy of the clinical review criteria used by us to make the adverse determination. The notice will also specify additional information or documentation needed, if any, for us to make a Level One internal appeal determination.

d. The provider who rendered care for which benefits are denied may request a Level One internal appeal of the retrospective adverse determination on your behalf (even if not authorized in writing by you to act as your designee).

4. Review of adverse determinations.

a. Request for Level One Internal Appeal

I. You, your authorized designee, and, in a retrospective review case, your lealth care provider may request a Level One internal appeal of an adverse determination, verbally or in writing, within 60 business days from the date that you receive notice of the adverse determination. To request a Level One Internal Appeal verbally, you may call 1-877-223-1685. To submit a written request for a Level One Internal Appeal, you may write to AETNA, P. O. Box 981109, El Paso, TX 79998-1109.

II The procedure that we will follow in reviewing your case will differ, depending upon the urgency of the case. In most cases, a standard Level One Internal Appeal, described below, will be appropriate. In "urgent cases", an expedited Level One Internal Appeal is available; expedited Level One nternal Appeal is described after standard Level One Internal Appeal below.

b. Standard Level One Internal Appeal.

I. Aetna will acknowledge your Level One Internal Appeal in writing, within 5 business days after receiving it.

II. When one or more Level One Internal Appeals are received (for example, you submit an appeal, then your health care provider submits an appeal on your behalf), a single Level One Internal Appeal will be conducted by a clinical peer reviewer (a physician who possesses a current and valid nonrestricted
license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current and valid nonrestricted license, certification, or registration or, where no provision for a license, certificate, or registration exists, is credentialled by the national accrediting body appropriate to the profession and is in the same profession/specialty as the health care provider who typically manages the medical condition), who did not make the initial adverse determination.

Ill. The clinical peer reviewer will render a determination within 30 calendar days after receipt of all necessary information. Written notice of the determination will be provided to you and any other qualified party who submitted a Level One Internal Appeal within 2 business days after the determination is made, but in no event later than 30 calendar days after receiving all necessary information. Failure to render a determination within the time periods required by Article 49 of the New York Insurance Law will be deemed to be a reversal of the initial adverse determination.

IV. The notice will include detailed reasons and the clinical rationale for the determination. If the determination is adverse, the notice will describe the procedure for filing an external appeal of the adverse determination. The external appeal process is described in paragraph e. Below. Note-if you submit a Level Two Internal Appeal, the review appeal may take longer than the 45-day time frame for requesting an external appeal through New York State, which begins on the date you receive the final adverse determination notice upon completion of Level One Internal Appeal.

c. Expedited Level One Appeal.

I. For cases involving a prospective or concurrent (but not retrospective) review decision (such as the review of continued or extended health care services; additional services rendered in the course of continued treatment; or any other issue with respect to which a provider requests an immediate review), you, your authorized designee, or a provider may request an expedited Level One Internal Appeal of the initial adverse determination.

II. When a request for expedited Level One Internal Appeal is received, the appeal will be conducted by a clinical-peer reviewer (defined in paragraph b.11. above) who did not render the initial adverse determination. AETNA will provide reasonable access to the clinical peer reviewer assigned to the appeal, within 1 business day following receipt of notice of the request for appeal, to ensure that all relevant information is available to the clinical peer reviewer. You may ask that your provider and the clinical peer reviewer exchange information by telephone or fax.

III. Within 48 hours of receipt by us of all information needed for the appeal, the clinical peer reviewer will render a determination on the expedited Level One Internal Appeal. Failure to render a determination within the time periods required by Article 49 of the New York Insurance Law will be deemed to be a
reversal of the initial adverse determination.

IV. Notice will be provided to you and the provider, by telephone and in writing, within 24 hours of the determination. The notice will include all of the information described and enclosed in a notice of standard Level One Internal Appeal determination (see paragraph b. IV. above). Note-If you request a Level Two Internal Appeal, the appeal may take longer than the 45-day time frame for requesting an External Appeal through New York State, which begins on the date you receive the final adverse determination notice upon completion of Level One Internal Appeal.

d. Level Two Internal Appeal.

I. After you receive notice of a Level One internal appeal determination, if you are still not satisfied, you or your authorized designee may submit a Level Two Internal Appeal, verbally or in writing. (You also have an option to apply for an external appeal; see paragraph e. below). The Level Two Internal Appeal must be received by Aetna within 60 business days from the date of the Level One Internal Appeal determination.

II. Aetna will acknowledge your Level Two Internal Appeal, in writing, within 15 calendar days after receiving it. The acknowledgment will identify additional information, if any, needed for the Level Two Internal Appeal.

III. Your case will be reviewed by at least one clinical peer reviewer (defined in paragraph b. 11. above) who did not make the prior determinations.

IV. In "urgent cases" where a delay would significantly increase the risk to your health, Aetna will make a Level Two Internal Appeal determination and call you within the lesser of 2 business days or 72 hours after receiving all information needed for the review. Written notice of the Level Two Internal Appeal
determination will also be provided within 2 business days.

In all other cases, Aetna will make a Level Two Internal Appeal determination within 30 business days after receiving all information needed for the review. Written notice of the determination will be provided to you within 2 business days after the determination is made, but in no event later than 30 business
days after receiving all necessary information.

V. The notice you receive will include detailed reasons for the Level Two Internal Appeal determination and, if a clinical matter is involved, the clinical rationale for the determination. The notice will also advise you of the right to apply for an external appeal, if the time frame for applying has not expired by
the date of receipt of notice of an adverse determination on Level Two Internal Appeal.

e. External Appeal.

I. In general. You have the right to an "external appeal" of certain coverage determinations made by us or on our behalf. An external appeal is an independent review of a coverage determination by a third party known as an External Appeal Agent. External Appeal Agents are certified by New York State; and may not have a prohibited affiliation with any health insurer, health maintenance organization (HMO), medical facility, or health care provider associated with the appeal. In this section, "requested service" or "requested services" refers to the service or services for which you are requesting coverage.

You may have the right to an expedited external appeal if your attending physician attests that a delay in providing the requested service would pose an imminent or serious threat to your health. The time frames for expedited external appeals are shorter than the time frames for standard external appeals.

You may request external appeal only if the requested service is covered under the health plan.

II. Coverage determinations subject to external appeal. This subparagraph describes the general conditions for external appeal. In general, you may not request an external appeal unless we have issued a "final adverse determination" with respect to your request for coverage after our Level One Internal Appeal (paragraph b. and c. above). You may ask us to agree to an external appeal even though you have not obtained a final adverse determination after Level One Internal Appeal; however we have no obligation
to agree to your request. If we do agree, we will send you a letter stating that we have agreed to an external appeal even though you have not obtained a final adverse determination.

To be eligible for external appeal, the final adverse determination issued upon completion of our Level One Internal Appeal must be based on a determination that the requested service is not medically necessary, or that the requested service is experimental and/or investigational. You do not have the right to an external appeal of any other determinations, even if those other determinations affect your coverage.

III. Conditions for external appeal of determinations of medical necessity. You may request an external appeal of a final adverse determination of medical necessity that is issued upon completion of Level One Internal Appeal if you meet the conditions of this subparagraph and the general requirements of subparagraph 11, above. The provisions of this subparagraph apply only to external appeal of medical necessity determinations. To request external appeal under this subparagraph, the final adverse determination must indicate that the requested service is or was not medically necessary.

Subparagraph VII. Below provides information on requesting an external appeal.

IV. Conditions for external appeal of determinations involving experimental and/or investigational treatment. This subparagraph governs the external appeal of determinations involving experimental
and/or investigational treatment. This subparagraph does not govern determinations involving services provided in clinical trials, which are governed by subparagraph V. below.

To request an external appeal under this subparagraph, your attending physician must certify that you have a life-threatening or disabling condition or disease. A "life-threatening condition or disease" is one that, according to the current diagnosis of your attending physician, has a high probability of causing your death. A "disabling condition or disease" is any medically determinable physical or mental impairment that can be expected to result in death; or that has lasted or can be expected to last for a continuous period of not less than 12 months; that renders you unable to engage in any substantial gainful activities. In the case of a child under the age of 18, a disabling condition or disease is any medically determinable physical or mental impairment of comparable severity

In addition, your attending physician must certify that: standard health services or procedures have been ineffective, or would be medically inappropriate in treating your life-threatening condition or
disease; or that no more beneficial standard treatment exists that is a covered service under the contract.

Your attending physician must have recommended a health service or procedure (including off-label usage of a pharmaceutical product) that, based on at least two documents from the available medical
literature, is likely to be more beneficial to you than any standard covered health service or procedure.

To make this recommendation, your attending physician must be board-certified or board-eligible and qualified to practice in the area appropriate to treat your life-threatening or disabling condition or
disease.

If you meet the requirements of this subparagraph and all of the requirements of subparagraph 11. above, you may request an external appeal. Subparagraph VII. provides information on requesting an external appeal.

V. External appeal of determinations involving clinical trials. This subparagraph governs the external appeal of determinations involving services provided in clinical trials.

To request an external appeal under this subparagraph, your attending physician must certify that you have a life-threatening or disabling condition or disease as described in subparagraph IV. above. In addition, your attending physician must certify that a clinical trial for your condition exists and that you are eligible to participate in the clinical trial. Your attending physician must also recommend that you participate in the clinical trial. To make this recommendation, your attending physician must be board-certified or board-eligible and qualified to practice in the area appropriate to treat your life-threatening or disabling condition or disease.

The clinical trial for which you are requesting coverage must be peer-reviewed, reviewed and approved by a qualified Institutional Review Board, and approved by one of the following:

> The National Institutes of Health (NIH), an NIH cooperative group or NIH center, the Food and Drug Administration, or the Department of Veterans Affairs;

> An entity that has been identified by the NIH as a qualified non-governmental research entity; or

> An Institutional Review Board of a facility that has a multiple project assurance approved by the Office of Protection from Research Risks of the NIH.

If you meet the requirements of this subparagraph and all of the requirements of subparagraph 11. above, you may request an external appeal. Subparagraph VII. below provides information on requesting an external appeal.

VI. Effect of the External Appeal Agent's decision: coverage. The decision of the External Appeal Agent is binding on both parties. If the External Appeal Agent decides in the Health Plan’s favor, we will not cover the requested service. If the external appeal agent decides in your favor, we will cover the service as follows:

> For services denied as not medically necessary, we will treat the service as medically necessary and provide coverage subject to all other conditions of the Plan...

> For services denied as experimental and/or investigational, other than services provided in a clinical trial, we will pay for the patient costs you incur for the services, subject to all other conditions of the
Plan.

> For services denied as experimental and/or investigational that are provided in a clinical trial, we will cover the costs of health services required to provide treatment according to the design of the trial,
subject to all other conditions of the Plan. We are not required to pay for drugs or devices that are the subject of the clinical trial.

We will not provide coverage for any service that is not a covered service under the Plan. In addition, this external appeal right does not alter your cost-sharing responsibilities, if any, as otherwise provided for in the Plan.

VII. Requesting an external appeal. If you meet the conditions described in this paragraph e., you may request an external appeal by filing a standard external appeal request form with the New York State Insurance Department. If the requested service has already been provided to you, your physician may file an appeal on your behalf. Aetna will send a standard external appeal request form to you when we have made a final adverse determination upon completion of Level One Internal Appeal. If your provider requested the Level One Internal Appeal of a retrospective adverse determination, Aetna will send your provider a standard provider external appeal request form with the notice of final adverse determination. You or your physician may obtain additional standard request forms at any time by calling the New York State Insurance
Department at 1-800-400-8882 or by accessing its website (www. ins. state. ny. us) by calling the New York Department of Health at 1-518-486-6074 or by accessing its website (www. health. state. ny. us), or by calling AETNA.

You must file your request for an external appeal with the New York State Insurance Department within 45 days of receiving a final adverse determination upon completion of Level One Internal Appeal; or within 45 days of receiving a letter from us waiving the internal review process. We do not have the authority to grant extensions of this deadline.

A Level Two Internal Appeal is available to you as an alternative to external appeal (see paragraph d. above); our Level Two Internal Appeal is optional. However, whether or not you request a Level Two Internal Appeal, your application for external appeal must be filed with the New York State Insurance Department within 45 days from your receipt of the notice of final adverse determination upon completion of Level One Internal Appeal, to be eligible for review by an external appeal agent.

You may be charged a fee of up to $50 to request an external appeal, which may be waived if we determine that paying the fee is a financial hardship. The fee is returned if your external appeal is successful.

If you do not understand any part of the external appeal process or if you have questions regarding your right to external appeal, you may contact us, the New York State Insurance Department, or the New York State Department of Health.

We urge you, but you are not required, to exhaust all levels of the applicable grievance procedure and/or utilization review procedure, before taking any further action with respect to our handling of your case. If you are not satisfied, you may contact the New York State Insurance Department at 1-800-342-3736 at any time during the review process. Upon request, we will provide you with the appropriate address for writing to the Insurance Department.