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B. External Review Provisions: An Adverse Determination Appeal may be submitted for External Review when the amount in dispute exceeds $500 unless the Provider notifies the Company that the Provider intends to submit additional Adverse Determination Appeals for External Review on the same or similar issues during the one-year period following the submission of the original Adverse Determination Appeal and the cumulative amount in dispute over the one-year period exceeds $500. The request for External Review is at the option of the Provider, who may instead choose any other dispute resolution allowed by the Agreement. If chosen, the External Review shall be binding. 2. The Adverse Determination Appeal must be submitted to Company in writing. The Administrative Manual and the Appeal Form for Provider Billing Dispute and Medical Necessity Denial provides detailed contact information. 3. Company will forward Adverse Determination Appeals that meet the prerequisites as listed in section A above to a designated External Review Organization. The Provider shall pay a filing fee of $50.00 for each Adverse Determination Appeal. (a) The Company shall notify the Provider the filing fee is due (b) Payment must be submitted before the External Review begins; provided, however, that the Provider shall be entitled to a refund of such payment in the event that the Provider prevails in the External Review process. (c) Provider shall submit the filing fee within sixty (60) calendar days of notice from the Company that filing fee is due or the External Review request will be closed. 5. Upon receipt of a timely filing fee, Company will provide to the External Review Organization the Appeal Record. 6. The External Review Organization will process the Adverse Determination Appeal and notify the Provider and Company of its recommendation within thirty (30) calendar days of receipt of the filing fee. The decision will be binding on Company and the Provider. 7. In the event that the External Review decision requires payment by Company, such payment shall be initiated within fifteen (15) calendar days after we receive notice of the determination. External Audit and Investigation Appeal Process The External Audit and Investigation Appeal Process is intended to give you an opportunity to request reconsideration of audit findings issued by our External Audit and Investigation Department and to ensure we have reviewed all information relevant to the audit findings. Please note that contract terminations resulting from audit findings must follow the Provider Contract Termination Appeal Process. A. Reconsideration Request Upon receipt of our audit findings, you have forty-five (45) business days to review and dispute these findings before the audit becomes final. In order to appeal the findings, you must submit a written request for a reconsideration of audit findings. You will be given the address for where to send your reconsideration request with your audit findings. Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 4 of 9