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Level One Appeals meetings are held on a bi-monthly basis. Your appeal will be scheduled for review at the next available Level One Appeal Panel meeting, subject to the time that your appeal request and any additional information is received and the volume of appeals being reviewed by the panel. If additional information is requested, it must be submitted within fifteen (15) business days of the date of the written request for information, unless a written request for a reasonable extension of time is granted. ■ If the information is not received on time, a decision will be made at the next Level One Appeal Panel meeting, based on the limited information available. • If the additional information is received on time, the new information will be taken into consideration at the next Level One Appeal Panel meeting. Information not submitted within the time limit will not be considered for the Level One Appeal, unless otherwise allowed by the Level One Appeal Panel. You will receive a written determination within ten (10) business days of the Level One Appeal Panel decision. The Level One Appeal decision is deemed final on the thirtieth (30th) business day after you receive it, unless a written request for a Level Two Appeal is received timely. B. Level Two Appeal — "In -Person Hearing" If you are not satisfied with the results of the Level One Appeal, you may submit a written request to the Credentialing Department, at the address listed below, for a Level Two Appeal, "in-person hearing" no later than thirty (30) business days after your receipt of the Level One Appeal decision. Provider Contract Termination Appeal - Level Two Attention: Credentialing Department P.O. Box 21267, M/S S-555 Seattle, WA 98111-3267 The Level Two Appeal Panel is comprised of at least three (3) individuals that have not been directly involved in the Level One Appeal, the Credentialing Committee, or the 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. The request for a Level Two Appeal must identify in detail the following: • All issues on which you request re-evaluation At election of the Provider, notification that more than two (2) hours is needed for the hearing • Information not previously submitted to the Level One Appeal panel, if any (Exception: We expect 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 The hearing is generally completed within two (2) hours and will be scheduled for two (2) hours, unless you notify us when requesting your Level Two Appeal that additional time is needed. We will make our best efforts to accommodate reasonable requests for additional time, as long as we are notified when you request the Level Two Appeal. Upon receipt of the Level Two Appeal request, we will send you an acknowledgement letter within fifteen (15) business days. Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 7 of 9