Form of Written Resolution of the Internal Appeal

(1) Each written resolution of an internal appeal shall include a clear summary explanation of the basis for the decision, including a substantive clinical justification for the decision, and identification of the specific information considered. (2) The written resolution on the Patient’s appeal shall prominently provide information on the Patient’s right to appeal the decision to the Office of Patient Protection and information on how to file a request for external review including, but not limited to: (a) A paper copy of the form prescribed by the Office of Patient Protection for the request for external review, as well as instructions for locating the form on the Office of Patient Protection’s website; (b) The toll-free number, website, and email address maintained by the Office of Patient Protection; and (c) A list of documents and information available to the Patient from the RBPO or ACO, including a list of the Patient’s medical records and other documents and information relied upon by the RBPO or ACO in the internal appeal. The RBPO or ACO shall include instructions for obtaining these documents.