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C. Review Process 1. The individual reviewing the issue(s) on appeal will meet the following criteria: (a) Is not an individual who made or consulted in the initial determination, (b) Is not a subordinate of an individual involved in the initial determination. 2. If the initial determination is upheld, you have the option to seek External Review or one of the other dispute resolution processes set forth in the Agreement. A description of the External Review option will be supplied, including the time limit for requesting External Review. The time limit for requesting External Review is ninety (90) calendar days after the written Internal Review determination. 3. Company will communicate a written decision on an Internal Review of an Adverse Determination Appeal within thirty (30) calendar days of our receipt of all documentation reasonably needed to make the determination. A description of the External Review option will be supplied with the written decision, including the time limit for requesting External Review. D. Adverse Determinations Not Eligible for Adverse Determination Appeals The following will not be considered to be eligible appeals: 1. Except for Billing Disputes, appeals made by non contracting providers. Appeals by non contracting providers may be eligible for the member appeal process. 2. Appeals of post service claims where the member or Provider sought a pre -service appeal of the same claim. 3. Appeal of a post service claim where the member has appealed the same claim. 4. The member has filed suit under Section 502 of ERISA or other suit for denial of the health care services or supplies regarding an Adverse Determination. E. Qualified Reviewer For an Internal Review pertaining to an Adverse Determination Appeal (not to include Billing Disputes), only a medical or dental practitioner holding an active, unrestricted license, who possesses the appropriate level of training and/or expertise required to evaluate the necessity of the service under review, and who is other than the one that made the initial Adverse Determination, may deny the appeal of the Provider who treated the condition. A nurse or other health care professional employed by Company may review the Adverse Determination Appeal and may grant but not deny it. If the nurse or other health care professional does not grant the appeal, then a Qualified Reviewer, designated by Company, other than the one that made the initial Adverse Determination, shall review and decide the Adverse Determination Appeal in accordance with our medical and reimbursement guidelines. Provider External Review Process If the initial determination is upheld through the Internal Review process, the option to seek External Review of the determination will be made available. A. Prerequisites for External Review 1. The Internal Review process must be exhausted before requesting an External Review of the determination unless both Company and the Provider agree in writing to forego the Internal Review process and proceed directly to External Review. 2. A Provider who chooses External Review will submit a written notice to Company within ninety (90) calendar days from the date of the Internal Review Determination. Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 3 of 9