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However spasms small intestine purchase rumalaya liniment in united states online, about 17% of the also been used in dental alloys since female population are already sensitised artificial dental restorations were first to spasms posterior knee purchase 60 ml rumalaya liniment with mastercard Nickel; they are at risk if supplied developed muscle relaxant otc meds buy rumalaya liniment 60 ml without prescription. Socalled Silver allergies containing dust is carcinogenic; the to spasms definition order rumalaya liniment 60 ml with mastercard Silver jewellery are often caused by processing of Nickel alloys therefore nickelcontaining coatings. The typical with Platinum and other elements, Zinc Tin concentration in canned foods is is the most important hardening 20 50 mg/kg. The highest tolerable component in modern metalceramic level is considered 250mg/kg. After amounts of Tin released from dental Iron, Zinc is the most important essen alloys are negligible in comparison. Organically bound Tin, such as was More than one hundred enzymes in the used in the past in some medications human body contain Zinc as an essen and in fungicides, etc. Zinc deficiency, which ous to humans, but it is not released is relatively common, causes immune from precious metal dental alloys. Zinc is therefore used to strengthen the bodys defences and to treat heavy metal poisoning. Cerium Ce As another example of its importance, Cerium increases the strength of high Zinc is required for the breakdown goldcontent alloys. There familiar element to the body, any is not much known about the toxicology amounts consumed are quickly trans of Cerium. However, the toxic doses ported to parts of the body where it is identified in animal experimentation are needed. Allergies against Cerium are not of Zinc per day, which can be easily known to date. Because of the high recommended daily intake, Zinc poisoning is only pos sible when consuming large amounts. Allergic reactions to Zinc are not known at this time, and they are not expected given the high essential dose. In reducedgold metal ceramic alloys, Tin improves flowability and increases hardness. Metallic or inor ganically bound tin is only poisonous to humans in high concentrations. Essential Element amount / day Intake / day Systemic toxicity Cytotoxicity Allergies Beryllium 0. Some daily intake values are taken from the literature; others were estimated based on the composition of typical foods. Information on systemic toxicity comes from different sources in toxicological literature. Cytotoxicity information particularly takes into account examinations on murine fibroblasts. High cytotoxicity also results in a high antibacterial effect, which can certainly be considered a positive characteristic if the element has other positive biological properties. It is proven and only possible with steadily increasing market share, to be one of the leading alloy manufactures. Code solder 800 non-preciousalloys Herador solder V 800 1583 0000 Stahlgold solder 750 1380 0000 Stahlgold solder 910 1360 0000 Caution! Stahlgold solder 910 contains nickel and must not be used for individuals with known nickel sensitivity. Code sible to conduct practice jobs and pro Training Metal Set, consisting of duce show pieces with little expenditure 30g training metal of material. The casting features and 1g training lot 1 mechanical properties of training metals 6460 2012 1g training lot 2 are so similar to those of Type 3 (acc. Training Training solder 800, working temperature 800C, 3g pack 6460 2015 metal is free of beryllium, nickel, cad Training solder 700, working temperature 700C, 3g pack 6460 2016 mium and lead. Two training solders with working temperatures of 800C and 700C are available for soldering. Blend aesthetics, and for the electroforming gold is a precious metal paste consist process ing of pure gold, organic material, and ceramic particles. 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Advantages Enhances the metalceramic bond; particulary indicated for the galvano forming process Surface sealing of metal framework Reinforcement for all thin layered veneer surfaces Superior shade matching of ceramic veneers because of gold background Enhanced shade precision at crown margins Concealed weld joints before firing Closure of small coping perforations All prices are subject to change without prior notice in line with change of precious metals world prices at time of order received in Germany. The wide range of attachments, retainers and retention elements, root pins and anchorage systems offers precision solutions for all challenges in combination technique. We value our customers and our sales representatives understand the requirements and challenges involved and can always offer the best solution which provides the foundation of partnerships for many years. Code 1: 1 Angula Threaded cap Matrix Threaded tion height width cap mm mm Primary Secondary 30 5. 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DuoLock impression coping, Ms the impression coping for the DuoLock attachment is an accessory used for fxation of the attachment patrix when taking 5158 6480 5158 an impression in the patients mouth and for transferring the oral situation to the model when fabricating or repairing a denture DuoLock adhesive aid, Ms (only for smooth threaded cap Art. Code 1003 + 1013) this adhesive aid was specially developed for the adhesive 5333 technique with threaded caps in CrCo frameworks. Retention screw, Ms the brass retention screw is for use with adhesive aid and 5335 6480 5335 impression coping. It enables a restoration to be designed so that the existing intraoral primary units can be used as base and anchorage components for a fixed/removable restoration in case of possible loss of the abutment tooth. The LogaSun attachment guarantees optimum retention, even when it has been shortened by the maximum amount. 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Alternatively the reduction might be a true reduction in surgery and alternative interventions are replacing surgery such as joint injections muscle relaxant cephalon order rumalaya liniment 60 ml otc. Other factors were considered with further analysis: It does not appear to spasms after hemorrhoidectomy purchase generic rumalaya liniment online be due to spasms movie purchase 60 ml rumalaya liniment overnight delivery a data coding issue spasms throughout body cheap rumalaya liniment 60 ml visa. The rate of fusion has about doubled for all age-groups with the rate in the 40-59 years group, more than tripling since 2006/07. When fusion is performed with laminectomy it is most commonly done in patients with spinal stenosis. As noted above, the evidence of benefit for fusion is stronger for instability associated with spondylolisthesis, with laminectomy there is less agreement over benefits and any are considered small. Re-operation rates maybe higher for spinal fusion than for laminectomy or discectomy without fusion and higher with internal fixation devices than bony fusion Page 51 National Health Committee Low Back Pain: A Pathway to Prioritisation (32) alone. Subsequent fusion procedures were performed a mean of 30 months after the original. Of the remainder about 7% had their spinal fusion after a previous hospitalisation for another surgical procedure type and about 1% had another surgical procedure after fusion. Repeat surgery after spinal fusion appears low compared to international published estimates, though the timescales may be too short to give a true reflection and the method used may under-estimate further surgical episodes. The total time for follow-up may be inadequate to capture all re operations and inadequate for those with recent first operations. This may reflect differences in the clinical presentation of patients but may also reflect a lack of clinical consensus regarding the optimal choices for clinical care. The rates are similar in the larger more specialised centres of the Auckland region, Wellington and Canterbury. However, privately funded spinal fusion numbers are only reliably available for those provided by Southern Cross. In the three most recent years for which data is available around 340 spinal fusions have been funded annually through Vote:Health. To provide some insight as to why non-surgical patients are admitted the first three procedure codes for these admissions were searched and categorised (Table 17 and Table 18). For the non surgical admissions, where codes are present it can be seen that those admitted acutely Page 55 National Health Committee Low Back Pain: A Pathway to Prioritisation predominantly have diagnostic procedures and that those admitted electively predominantly have injections. The elective admissions are likely to be explained as day-case events, but these have not been specifically identified in this analysis. Patients appear to be being admitted for pain relief with a package of care including attendance to any social issues and perhaps introduction to physical therapy being wrapped around the patient while theyre in hospital. Additionally, if the acute discharges are explained by emergency department attendances, these may be explained by inadequate access to pain control services in the community. The reason for the increase in the non-surgical discharge rate is not clear and in particular the greater increase related to acute admissions. However the proportions are close to 100% and so the data regarding contact with other services may be assumed to be a reasonable reflection of actual service use. It is notable that about 81% of patients have seen a physiotherapist, 12% an osteopath and 13% a chiropractor. Table 20: Summarised pathway of secondary publically funded care for Vote:Health publicly funded surgical patients in 2012/13 Pathway of care components Percent Only Surgery 2. The low figure for patients only having surgery in the public system could be explained by pre and post care being delivered in the private system. Of these surgical patients 45% appear to receive only orthopaedic outpatients contact and about 76% have orthopaedic contact. Physiotherapy services were received by 39% of surgical patients and 51% had received pain modifying medication (anti-depressants or anticonvulsants). Of those patients, indicated to have received pain services, about 50% receive them before hospitalisation and 50% after. More surgical patients are accessing pain services prior to surgery (67%) which would be expected. For non-surgical patients access to pain services is greater after hospitalisation (59%) possibly in keeping with these patients being admitted in part for pain relief and diagnostic assessment. The results of this analysis may be compromised by the quality of the data collection but do appear outside reported clinical experience. The number of patients is small but 31% received physiotherapy and 9% were seen by an orthopaedic surgeon. In contrast for the public system patients 22% received physiotherapy and 5% pain interventions. For the Vote:Health publicly funded patients the data for services received is less reliable and limited to the two year period around their hospital event. The average national price of a surgical discharge is about $18,000 and for spinal fusion (with or without laminectomy) is $23,300. Southern Cross Health Society provides coverage for about 61% of the insured population in New Zealand. The number of insured adults in 2015 is about the same as 2006 with a peak in 2009, about 20 2. Southern Cross total surgical volumes for lower back episodes varied per annum from 600 to 850 in the period 2006/07 to 2013/14, with more recent years at the higher end. In this period average costs per episode steadily increased from around $12,000 to over $22,000. Southern Cross spinal fusion volumes varied over the period ranging from 184 to 257 per annum, with average costs showing a similar steady increase in average cost, from around $24,000 to $45,000. Assessment for Analgesia first and second line red flags and yellow flags Manual Therapies Vote:Health funded N = 49,000 per year Cost = $7. The reliability of the cost estimates vary, however, depending on the data sources and the assumptions that have had to be made. Currently, there is no full Model of Care approach that provides a clear pathway across acute and chronic. It appears the peak seems to have been reached and there has been a slight decline in recent years. Reasons for this decline are not known but may feasibly be accounted for by a change in clinical behaviour or provision of alternative treatments. Reasons to explain the historical increase in spinal surgical discharges are likely multifactorial; including improvements in diagnostic imaging identifying the likely cause of pain, the development of surgical techniques to treat a greater range of conditions, increased numbers of and access to orthopaedic spinal specialists, and patients desiring to remain active into old age. There has been an increasing trend over time in the procedure rate of spinal fusion, across all age groups, with the rate stabilising in more recent years. The use of spinal fusion has been expanded to include pain from degenerative diseases, with the majority of procedures now performed being for spondylosis (spinal degenerative diseases), disc disorders and spinal stenosis (in the absence of (32) deformities). The clinical outcomes of spinal fusion are variable, leading to continuing debate (32) about which patients might benefit from the procedure. It is estimated that the cost of fusion surgery for mechanical and non-specific low back problems was about $8 million for 2013/14. However, fusions are performed in conjunction with other spinal surgery, though the cost of fusion with laminectomy is similar to that without laminectomy. Page 64 National Health Committee Low Back Pain: A Pathway to Prioritisation the appropriateness of surgery with reference to a patients clinical condition is more nuanced than can be considered from the analysis of administrative data. This could indicate that some patients are not receiving beneficial surgery or that some patents are receiving surgery that is less beneficial. Overuse of surgery may reflect variation in the assessment of clinical benefit but also could be a reflection on the inadequate provision of effective non-surgical management options. Effective treatment, earlier in the patients course, improves outcomes and prevents the development of chronicity and so provision earlier in the model of care may reduce the number of patients with more severe clinical conditions presenting to specialist services. There appears to be geographical variation in the provision and variation in the pain management components offered. In conjunction with assessing specialist pain services in secondary care, the provision of pain services in the primary care/community setting delivered earlier in the clinical course could also be assessed. The various components of pain services could be considered, their relative effectiveness within the service delivered and the transferability of these interventions to alternatives settings. Evidence suggests that manual therapies and structured exercise programmes improve health outcomes, and are considered modestly effective. Additionally structured exercise programmes are considered effective in reducing pain and disability though the effect is small but cost effective (12) compared to general care. A stratified approach to the provision of physiotherapy shows (15) improvement in disability, quality of life and cost savings compared to standard care. The New Zealand Council of Medical Colleges is spearheading the astute application of the New Zealand version of the appropriate use of resources / Choosing Wisely thinking in this area. Patients who do not have surgery appear to be hospitalised for diagnostic reasons and for delivery of therapeutic injections.

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Either (1) or (2): (1) There are insufficient symptoms to muscle relaxant intravenous rumalaya liniment 60 ml without a prescription meet the criteria of any of the sub-types F20 spasms stomach area buy rumalaya liniment on line. The depressive symptoms must be sufficiently prolonged muscle relaxant bodybuilding cheap rumalaya liniment 60 ml line, severe and extensive to infantile spasms 9 month old order rumalaya liniment 60 ml mastercard meet criteria for at least a mild depressive episode (F32. Slowly progressive development over a period of at least one year, of all three of the following: (1) A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of drive and interests, aimlessness, idleness, a self-absorbed attitude, and social withdrawal. Absence of evidence of dementia or any other organic mental disorder listed in section F0. The subject must have manifested, over a period of at least two years, at least four of the following, either continuously or repeatedly: (1) Inappropriate or constricted affect, subject appears cold and aloof; (2) Behaviour or appearance which is odd, eccentric or peculiar; (3) Poor rapport with others and a tendency to social withdrawal; (4) Odd beliefs or magical thinking influencing behaviour and inconsistent with subcultural norms; (5) Suspiciousness or paranoid ideas; (6) Ruminations without inner resistance, often with dysmorphophobic, sexual or aggressive contents; (7) Unusual perceptual experiences including somatosensory (bodily) or other illusions, depersonalization or derealization; (8) Vague, circumstantial, metaphorical, over-elaborate or often stereotyped thinking, manifested by odd speech or in other ways, without gross incoherence; (9) Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusion-like ideas, usually occurring without external provocation. The subject must never have met the criteria for any disorder in F20 (Schizophrenia). The presence of a delusion or a set of related delusions other than those listed as typical schizophrenic under F20 G1. The commonest examples are persecutory, grandiose, hypochondriacal, jealous (zelotypic)) or erotic delusions. Persistent hallucinations in any modality must not be present (but transitory or occasional auditory hallucinations that are not in the third person or giving a running commentary, may be present). Most commonly used exclusion criteria: There must be no evidence of primary or secondary brain disease as listed under F0, or a psychotic disorder due to psychoactive substance use (F1x. Specification for possible subtypes: the following types may be specified, if desired: persecutory type; litiginous type; self-referential type; grandiose type; hypochondriacal (somatic) type; jealous type; erotomanic type. Disorders in which delusions are accompanied by persistent hallucinatory voices or by schizophrenic symptoms that are insufficient to meet criteria for schizophrenia (F20. Delusional disorders that have lasted for less than three months should, however, be coded, at least temporarily, under F23. An acute onset of delusions, hallucinations, incomprehensible or incoherent speech, or any combination of these. The time interval between the first appearance of any psychotic symptoms and the presentation of the fully developed disorder should not exceed two weeks. If transient states of perplexity, misidentification, or impairment of attention and concentration are present, they do not fulfill the criteria for organically caused clouding of consciousness as specified in F05 A. The disorder does not meet the symptomatic criteria for manic episode (F30), depressive episode (F32), or recurrent depressive disorder (F33). No evidence of recent psychoactive substance use sufficient to fulfil the criteria of intoxication (F1x. The continued moderate and largely unchanged use of alcohol or drugs in amounts or frequencies to which the subject is accustomed does not necessarily rule out the use of F23; this must be decided by clinical judgement and the requirements of the research project in question. Most commonly used exclusion criteria: absence of organic brain disease (F0) or serious metabolic disturbances affecting the central nervous system (this does not include childbirth). A fifth character should be used to specify whether the acute onset of the disorder is associated with acute stress (occurring within two weeks prior to evidence of first psychotic symptoms). The general criteria for acute and transient psychotic disorders (F23) must be met. The symptomatology is rapidly changing in both type and intensity from day to day or within the same day. The presence of any type of either hallucinations or delusions, for at least several hours, at any time since the onset of the disorder. Symptoms from at least two of the following categories, occurring at the same time: (1) Emotional turmoil, characterized by intense feelings of happiness or ecstasy, or overwhelming anxiety or marked irritability; (2) Perplexity, or misidentification of people or places; (3) Increased or decreased motility, to a marked degree. The disorder does not meet the criteria B, C and D for acute polymorphic psychotic disorder (F23. Relatively stable delusions and/or hallucinations are present, but they do not fulfil the symptomatic criteria for schizophrenia (F20. The disorder does not meet the criteria for acute polymorphic psychotic disorder (F23. The subject must develop a delusion or delusional system originally held by someone else with a disorder classified in F20-F23. The two people must have an unusually close relationship with one another, and be relatively isolated from other people. The subject must not have held the belief in question prior to contact with the other person, and must not have suffered from any other disorder classified in F20-F23 in the past. The disorder meets the criteria of one of the affective disorders of moderate or severe degree, as specified for each sub-type. Symptoms from at least one of the symptom groups listed below, clearly present for most of the time during a period of at least two weeks (these groups are almost the same as for schizophrenia (F20. Criteria G1 and G2 must be met within the same episode of the disorder, and concurrently for at least some time of the episode. Most commonly used exclusion criteria: the disorder is not attributable to organic brain disease (in the sense of F0), or to psychoactive substance-related intoxication, dependence or withdrawal (F1). The criteria for depressive disorder, at least moderate severity must be met (F32. Include here also combinations of symptoms not covered by the previous categories of F20, such as delusions other than those listed as typical schizophrenic under F20 G1. The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least four consecutive days. At least three of the following must be present, leading to some interference with personal functioning in daily living: (1) increased activity or physical restlessness; (2) increased talkativeness; (3) difficulty in concentration or distractibility; (4) decreased need for sleep; (5) increased sexual energy; (6) mild spending sprees, or other types of reckless or irresponsible behaviour; (7) increased sociability or over-familiarity. Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1) or any organic mental disorder, in the sense of F0. A mood which is predominantly elevated, expansive or irritable and definitely abnormal for the individual concerned. This mood change must be prominent and sustained for at least a week (unless it is severe enough to require hospital admission). The absence of hallucinations or delusions, although perceptual disorders may occur. Mot commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1) or any organic mental disorder, in the sense of F0. The episode does not simultaneously meet the criteria for schizophrenia (F20) or schizo-affective disorder, manic type (F25. Delusions or hallucinations are present, other than those listed as typical schizophrenic in F20 G1. The commonest examples are those with grandiose, self-referential, erotic or persecutory content. A fifth character may be used to specify whether the hallucinations or delusions are congruent or incongruent with the mood: F30. There has been at least one other affective episode in the past, meeting the criteria for hypomanic or manic episode (F30. There has been at least one other affective episiode in the past, meeting the criteria for hypomanic or manic episode (F30. A fifth character may be used to specify whether the psychotic symptoms are congruent or incongruent with the mood: F31. The current episode meets the criteria for a depressive episode of either mild (F32. A fifth character may be used to specify the presence of the somatic syndrome as defined in F32, in the current episode of depression: F31. The current episode meets the criteria for a severe depressive episode without psychotic symptoms (F32. The current episode meets the criteria for a severe depressive episode with psychotic symptoms (F32. A fifth character may be used to specify whether the psychotic symptoms are congruent or incongruent with the mood. The current episode is characterized by either a mixture or a rapid alternation. The current state does not meet the criteria for depressive or manic episode in any severity, or for any other mood disorder in F3 (possibly because of treatment to reduce the risk of future episodes). There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode (F30.

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In addition muscle relaxant dogs best buy for rumalaya liniment, Gateway Health can assist in connecting you with other state and local programs spasms with cerebral palsy buy discount rumalaya liniment 60 ml on line. If you need help with any part of your care spasms near temple order rumalaya liniment with amex, your childs care spasms discount rumalaya liniment, or coordinating that care with another state, county, or local program, please contact the Gateway Health Special Needs Unit for assistance. The Gateway Health Special Needs Unit will also assist members in transitioning care from services received in a hospital or temporary medical setting to care received at home. Please contact the Gateway Health Special Needs Unit for assistance in help receiving care in your home. We coordinate member care prospectively and holistically, taking into account not only immediate care needs, but also the social determinants of health and the need to coordinate between our members, providers and community resources. Special Needs Care coordination services include, but are not limited to: Assist member with timely access to services and benefits/care coordination/care transitions Assistance with locating referrals to community-based services as these impact Social Determinants of Health Collaboration with physicians, caregivers and other supports to assist members in coordinating their care. If you have questions about this program, please contact the Special Needs Unit at 1-800-392 1147. These allow for your wishes to be respected if you are unable to decide or speak for yourself. If the laws regarding advance directives are changed, Gateway Health will tell you in writing what the change is within 90 days of the change. It states what medical care you do, and do not, want to get if you cannot tell your doctor or other providers the type of care you want. Your doctor must have a copy and must decide that you are unable to make decisions for yourself for a Living Will to be used. Health Care Power of Attorney A Health Care Power of Attorney is also called a Durable Power of Attorney. A Health Care or Durable Power of Attorney is a document in which you give someone else the power to make medical treatment decisions for you if you are physically or mentally unable to make them yourself. To create a Health Care Power of Attorney, you may but do not have to get legal help. What to Do if a Provider Does Not Follow Your Advance Directive Providers do not have to follow your advance directive if they disagree with it as a matter of conscience. A Complaint is when you tell Gateway Health you are unhappy with Gateway Health or your provider or do not agree with a decision by Gateway Health. Some things you may complain about: You are unhappy with the care you are getting. Gateway Healths address and fax number for Complaints: Gateway Health Attn: Complaint and Grievance Department P. You must file a Complaint within 60 days of getting a notice telling you that Gateway Health has decided that you cannot get a service or item you want because it is not a covered service or item. You must file a Complaint within 60 days of the date you should have gotten a service or item if you did not get a service or item. After you file your Complaint, you will get a letter from Gateway Health telling you that Gateway Health has received your Complaint, and about the First Level Complaint review process. You may also send information that you have about your Complaint to Gateway Health. Gateway Health will tell you the location, date, and time of the Complaint review at least 10 days before the day of the Complaint review. A committee of 1 or more Gateway Health staff who were not involved in and do not work for someone who was involved in the issue you filed your Complaint about will meet to make a decision about your Complaint. If the Complaint is about a clinical issue, a licensed doctor will be on the committee. Gateway Health will mail you a notice within 30 days from the date you filed your First Level Complaint to tell you the decision 80 on your First Level Complaint. If you need more information about help during the Complaint process, see page 89. What to do to continue getting services: If you have been getting the services or items that are being reduced, changed or denied and you file a Complaint verbally, or that is faxed, postmarked, or hand-delivered within 10 days of the date on the notice telling you that the services or items you have been receiving are not covered services or items for you, the services or items will continue until a decision is made. You may ask for an external Complaint review, a Fair Hearing, or an external Complaint review and a Fair Hearing if the Complaint is about one of the following: Gateway Healths decision that you cannot get a service or item you want because it is not a covered service or item. You must ask for an external Complaint review within 15 days of the date you got the First Level Complaint decision notice. You must ask for a Fair Hearing within 120 days from the mail date on the notice telling you the Complaint decision. For all other Complaints, you may file a Second Level Complaint within 45 days of the date you got the Complaint decision notice. Gateway Healths address and fax number for Second Level Complaints Gateway Health Attn: Complaint and Grievance Department P. After you file your Second Level Complaint, you will get a letter from Gateway Health telling you that Gateway Health has received your Complaint, and about the Second Level Complaint review process. You may ask Gateway Health to see any information Gateway Health has about the issue you filed your Complaint about at no cost to you. Gateway Health will tell you the location, date, and time of the Complaint review at least 15 days before the Complaint review. You may appear at the Complaint review in person, by phone, or by videoconference. If you decide that you do not want to attend the Complaint review, it will not affect the decision. A committee of 3 or more people, including at least 1 person who does not work for Gateway Health, will meet to decide your Second Level Complaint. The Gateway Health staff on the committee will not have been involved in and will not have worked for someone who was involved in the issue you filed your Complaint about. Gateway Health will mail you a notice within 45 days from the date your Second Level Complaint was received to tell you the decision on your Second Level Complaint. You may ask for an external review by either the Department of Health or the Insurance Department. You must ask for an external review within 15 days of the date you got the Second Level Complaint decision notice. The Department of Health handles Complaints that involve the way a provider gives care or services. The Insurance Department reviews Complaints that involve Gateway Healths policies and procedures. If you send your request for an external review to the wrong Department, it will be sent to the correct Department. The Department of Health or the Insurance Department will get your file from Gateway Health. You may also send them any other information that may help with the external review of your Complaint. You may be represented by an attorney or another person such as your representative during the external review. This letter will tell you all the reason(s) for the decision and what you can do if you do not like the decision. When Gateway Health denies, decreases, or approves a service or item different than the service or item you requested because it is not medically necessary, you will get a notice telling you Gateway Healths decision. A Grievance is when you tell Gateway Health you disagree with Gateway Healths decision. Gateway Healths address and fax number for Grievances: Gateway Health Attn: Complaint and Grievance Department P. If your provider files a Grievance for you, you cannot file a separate Grievance on your own. You must file a Grievance within 60 days from the date you get the notice telling you about the denial, decrease, or approval of a different service or item for you. After you file your Grievance, you will get a letter from Gateway Health telling you that Gateway Health has received your Grievance, and about the Grievance review process. You may ask Gateway Health to see any information that Gateway Health used to make the decision you filed your Grievance about at no cost to you. You may also send information that you have about your Grievance to Gateway Health. Gateway Health will tell you the location, date, and time of the Grievance review at least 10 days before the day of the Grievance review. You may appear at the Grievance review in person, by phone, or by videoconference. If you decide that you do not want to attend the Grievance review, it will not affect the decision. A committee of 3 or more people, including a licensed doctor, will meet to decide your Grievance.

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