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If the Medical Director needs additional documentation to reach a decision, the additional documentation must be submitted within twenty (20) calender days of the date of the Medical Director's written request for lnfor1TU1Uon , unlees your written request ror 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 conUnue 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 e11pired . You will be sent written notice of the decision within forty.five (45) business days following the Medical Director Review_ The Medical Director Revle-w ls the fins.I stop In the External Audll and lnvesti911tt on Appeal Proc&1.a , once a decision hos been made by th o Modlcal Director, the Externa l Audlt and Investigation Appeal Process ha& boon completed and tho declalon shall be deemed nnel. If you are not satisfied with the Company's decision ofter completing fhe External Audit and Investigation Appeal Process and want lo oonUnue to dispute the issue(s), you must initiate the appropriate process(es) as outlined in your Provider contract. Provider Contract Termination Appeals A contracll!d provider may Initiate an appea l 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 mus_! send a written reque-91 to the Company's Cred erttlall ng Department, at the address listed below wi thin thirty (30) buslf\HS days of receipt of the termination no)lfiClll[on . Provider Contract Termination Appeal • Level One Attention: Crwdentlallng Department P.O. Box 21287, MIS S-555 Seattle, WA 98111-3267 A request for an appeal regarding a contract terminalion must include, at a minimum : • • • • A detailed description of the disputed issue(s) The basis for your disagreement with the deci9lon All evidence and documentation supporting yaur posrtlon (ExceptJon : Please note that ail documentation raqulred to jus~ry your billlng, including, but not limited to. chart notes, lo be present In your files al the lime or an audit. Addillons to file documenlatlon or the produeUon or flies that were not made available to Company at the time of an audJI will not be considered in connection with an appeal lnvotvlng adverse audit fi ndings. We will, however, consider your explanation as to why the documentation was not prese nt at the time or lhe audll ) Your requested outcome Upon receipt of the Level One Appeal request, we will send you an acknowledgement letter within fifteen (15) business d&J$, The Le.vel One Appeal Papel Is comprls:ed or at least three (3) indll/fduals that have not been d irectly lnvolv!!d in the Credentialing CommiJle;e or ler:rnin ellon decision and have the appropriate level of knowledge and traln ln,g to understand the Issues presented. At least one panel member must be a Participating Provider. Aauria Standard MGA EIChlbit O Dispute Resolutio~ Proce11 A1881685<1AA Page6 ofg