Section 3.404 - Form and Manner of Request for External ReviewRequests for external review submitted by the insured or the insured's authorized representative shall:
(1) be on a form prescribed by the Office of Patient Protection;(2) include the signature of the insured or the insured's authorized representative consenting to the release of medical information;(3) include a copy of the written final adverse determination issued by the carrier; and,(4) include the $25.00 fee required by 958 CMR 3.402 unless not required pursuant to 958 CMR 3.402(l)(a) or waived pursuant to 958 CMR 3.402(2).Amended by Mass Register Issue 1494, eff. 4/28/2023.