A Covered Person may file an appeal of a grievance decision orally or in writing. Our appeal procedures include the following: 1. Written or oral acknowledgment of the appeal not more than 5 business days after the appeal is filed. 2. Documentation of the substance of the appeal and the actions taken. 3. Notification to the Covered Person: a. of the disposition of an appeal; and b. that the Covered Person may have the right to further remedies allowed by law. 4. Standards for timeliness in: a. responding to an appeal; and b. providing notice to Covered Persons of the disposition of an appeal, and of the right to initiate an external grievance review under IC 27-8-29; that accommodate the clinical urgency of the situation. An appeal of a grievance decision shall be resolved: 1. as expeditiously as possible, reflecting the clinical urgency of the situation; and 2. not later than 45 days after the appeal is filed. We shall notify a Covered Person in writing of the resolution of an appeal of a grievance decision within 5 business days after completing the investigation. The appeal resolution notice shall include the following: 1. A statement of the decision reached by Us. 2. A statement of the reasons, policies, and procedures that are the basis of the decision. 3. Notice of the Covered Person's right to further remedies allowed by law, including the right to external grievance review by an independent review organization under IC 27-8-29. 4. The department, address, and telephone number through which a Covered Person may contact a qualified representative to obtain more information about the decision or the right to an external grievance review. 1. an adverse determination of appropriateness; 2. an adverse determination of medical necessity; 3. a determination that a proposed service is experimental or investigational; or 4. a denial of coverage based on a waiver described in IC 27-8-5-2.5 or IC 27-8-5-19.2; made by Us or an agent of Ours regarding a service proposed by the treating health care provider. Our external grievance procedure shall: 1. allow a Covered Person or a Covered Person's representative to file a written request with Us for an external grievance review of Our: a. appeal resolution of a grievance; or b. denial of coverage based on a waiver described in IC 27-8-5-2.5 or IC 27-8-5-19.2; not more than 45 days after the Covered Person is notified of the resolution; and 2. provide for: a. EXTERNAL REVIEW OF GRIEVANCES An external grievance procedure is available for the resolution of external grievances regarding: an expedited external grievance review for a grievance related to an illness, a disease, a condition, an injury, or a disability if the time frame for a standard review would seriously jeopardize the Covered Person’s life or health, or ability to reach and maintain maximum function; or b. standard external grievance review for a grievance not described in item 2.a. above. A Covered Person may file not more than one external grievance of Our appeal resolution. A Covered Person shall not pay any of the costs associated with the services of an independent review organization under this external review procedure. All costs must be paid by Us. A Covered Person who files an external grievance: 1. shall not be subject to retaliation for exercising the Covered Person's right to an external grievance;
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