OHIO DEPARTMENT OF INSURANCE MODEL NOTICE OF DENIAL OF

 EMPLOYEES’ COMPENSATION DIVISION LABOUR DEPARTMENT STATEMENT OF
BILL LOCKYER STATE OF CALIFORNIA ATTORNEY GENERAL DEPARTMENT OF
  COMMITTEE ASSISTANCE DEPARTMENT INTERNATIONAL & ENVIRONMENTAL PLANNING

  US DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION
DATE INDIANA DEPARTMENT OF TRANSPORTATION ATTN INDOT PROJECT MANAGER
STATE OF WISCONSIN DEPARTMENT OF ADMINISTRATION DIVISION OF ENTERPRISE

NOTICE OF DENIAL OF EXTERNAL REVIEW REQUESTS FOR ADMINISTRATIVE REASONS

OHIO DEPARTMENT OF INSURANCE

MODEL NOTICE OF DENIAL OF EXTERNAL REVIEW REQUEST

HEALTH PLAN ISSUER:

DATE OF NOTICE:

MAILING ADDRESS:

TELEPHONE:

FAX:

EMAIL ADDRESS:

WEBSITE ADDRESS:


COVERED PERSON/APPLICANT:

APPLICATION OR PLAN ID NUMBER:

MAILING ADDRESS:

DATE OF EXTERNAL REVIEW REQUEST:


THIS DOCUMENT CONTAINS IMPORTANT INFORMATION THAT YOU SHOULD RETAIN FOR YOUR RECORDS

This document serves as notice of a denial of a Request for External Review. We cannot approve your request for the reason indicated below. If you think this determination was made in error, you may have the right to appeal our decision to the Ohio Department of Insurance.


 Your request for external review is incomplete for the following reason(s):




Please be sure your request is complete before resubmitting it to us. To make a complete request, please include the following information:




 Your request for external review has been denied because the adverse benefit determination that is the basis for your request is not eligible for external review for the reason(s) shown below. You have the right to appeal this decision to the Ohio Department of Insurance by completing and returning to us the attached Request for Appeal of External Review Request Denial.




 You filed a request for an external review because we failed to provide a written notice about your internal appeal within the time frame required or we failed to follow all requirements of the internal appeal process. Ohio law does allow an exception under certain circumstances if the failure was due to de minimus (minor) violations that do not harm you. We believe the failure on our part was de minimus for the reason(s) shown below. You have the right to appeal this denial to the Ohio Department of Insurance by completing and returning to us the attached Request for Appeal of External Review Request Denial. (Your Request for Review by the Ohio Department of Insurance will not delay completion of the internal appeal currently in process.)



Be sure to keep a copy for yourself of this notice, your completed Appeal of External Review Request Denial (if applicable) and all documents and correspondence related to this review.

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ODI Model Notice of Denial of External Review Request

Rev’d. 05/23/2012-cdw


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