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If the Medical Director needs additional documentation to reach a decision, the additional documentation must be submitted within twenty (20) calendar days of the date of the Medical Director's written request for information, unless your written request for a reasonable extension of time is granted. ■ If the requested documentation is received on time, it will be included in the Medical Director Review. • If the documentation is not received on time, the Medical Director Review will continue and a decision will be made based on the information originally submitted. During the period of time in which the Company is waiting for additional information, the forty-five (45) business day clock to complete the Medical Director Review is suspended until the information is received or the time to respond to the request has expired. You will be sent written notice of the decision within forty-five (45) business days following the Medical Director Review. The Medical Director Review is the final step in the External Audit and Investigation Appeal Process. Once a decision has been made by the Medical Director, the External Audit and Investigation Appeal Process has been completed and the decision shall be deemed final. If you are not satisfied with the Company's decision after completing the External Audit and Investigation Appeal Process and want to continue to dispute the issue(s), you must initiate the appropriate process(es) as outlined in your Provider contract. Provider Contract Termination Appeals A contracted Provider may initiate an appeal of a contract termination decision made by Company through the Provider Contract Termination Appeal Process. IV. A. Level One Appeal To request a Level One Appeal, you must send a written request to the Company's Credentialing Department, at the address listed below within thirty (30) business days of receipt of the termination notification. Provider Contract Termination Appeal - Level One Attention: Credentialing Department P.O. Box 21267, M/S S-555 Seattle, WA 98111-3267 A request for an appeal regarding a contract termination must include, at a minimum: • A detailed description of the disputed issue(s) • The basis for your disagreement with the decision • All evidence and documentation supporting your position (Exception: Please note that all documentation required to justify your billing, including, but not limited to, chart notes, to be present in your files at the time of an audit. Additions to file documentation or the production of files that were not made available to Company at the time of an audit will not be considered in connection with an appeal involving adverse audit findings. We will, however, consider your explanation as to why the documentation was not present at the time of the audit.) • Your requested outcome Upon receipt of the Level One Appeal request, we will send you an acknowledgement letter within fifteen (15) business days. The Level One Appeal Panel is comprised of at least three (3) individuals that have not been directly involved in the Credentialing Committee or termination decision and have the appropriate level of knowledge and training to understand the issues presented. At least one panel member must be a Participating Provider. Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 6 of 9