Reconsideration If We did not attempt to consult with Your Provider who recommended the Covered Service before making an adverse determination, the Provider may request reconsideration by the same clinical peer reviewer who made the adverse determination or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable. For Preauthorization and concurrent reviews, the reconsideration will take place within one (1) business day of the request for reconsideration. If the adverse determination is upheld, a notice of adverse determination will be given to You and Your Provider, by telephone and in writing.
Reconsiderations and Appeals If you experience a problem relating to an authorization review, benefit denial, or other aspect of this plan, we have internal and external procedures to help you resolve your issue. The following sections detail the processes and procedures for filing: • Administrative Appeals; • Medical Reconsiderations and Appeals (including expedited appeals); • Prescription Drug Appeals: and
Adverse Benefit Determination An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.
Denial If NB denies the Applicant, NB shall furnish a written statement stating its reasons. The Applicant shall have the opportunity to discuss the decision with the Director of Social Services. The Applicant has the right to an administrative fair hearing. If NB denies an Applicant based in part on an indicated child abuse or maltreatment report, the Applicant has a right to a fair hearing regarding the report. The request must be made within 90 days of receiving the written denial notice. (See Disclosures, page 10.)
DISMISSAL, SUSPENSION AND DISCIPLINE 13 11.1 Procedure 13 11.2 Dismissal and Suspension 13 11.3 Burden of Proof 13 11.4 Right to Grieve Other Disciplinary Action 13 11.5 Personnel File 13 11.6 Right to Have Union Representative Present 14 11.7 Abandonment of Position 14 11.8 Probation 14 11.9 Employee Investigations 15 ARTICLE 12 - SENIORITY 15 12.1 Seniority Defined 15 12.2 Seniority List 16 12.3 Loss of Seniority 16 12.4 Re-Employment 17 12.5 Bridging of Service 17 12.6 Same Seniority 17 ARTICLE 13 - LAYOFF AND RECALL 17 13.1 Definition of a Layoff 17 13.2 Pre-Layoff Canvass 17 13.3 Layoff 18 13.4 Bumping 18 13.5 Recall 19 13.6 Advance Notice 19 13.7 Grievance on Layoffs and Recalls 19 13.8 Worksite Closure 19 ARTICLE 14 - HOURS OF WORK 20 14.1 Definitions 20 14.2 Hours of Work 20 14.3 Rest Periods 21 14.4 Meal Periods 22 14.5 Flextime 22 14.6 Staff Meetings 22 (ii) 14.7 Standby Provisions 22 14.8 Conversion of Hours 23 ARTICLE 15 - SHIFTS 23 15.1 Exchange of Shifts 23 15.2 Shortfall of Shifts 23 15.3 Short Changeover Premium 23 15.4 Split Shifts 23 15.5 Work Schedules 23 ARTICLE 16 - OVERTIME 24 16.1 Definitions 24 16.2 Overtime Entitlement 24 16.3 Recording of Overtime 24 16.4 Sharing of Overtime 24 16.5 Overtime Compensation 24 16.6 No Layoff to Compensate for Overtime 24 16.7 Right to Refuse Overtime 25 16.8 Callback Provisions 25 16.9 Rest Interval 25 16.10 Overtime for Part-Time Employees 25 16.11 Authorization and Application of Overtime 25 ARTICLE 17 - HOLIDAYS 26 17.1 Paid Holidays 26 17.2 Holiday Falling on Saturday or Sunday 26 17.3 Holiday Falling on a Day of Rest 26
Notice of Dismissal or Suspension Notice of dismissal or suspension shall be in writing and shall set forth the reasons for dismissal or suspension, and a copy shall be sent to the President of the Union or his/her designate.
How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.
Appeal (1) An appeal against a decision of the Court of First Instance may be brought before the Court of Appeal by any party which has been unsuccessful, in whole or in part, in its submissions, within two months of the date of the notification of the decision.
Procedure for Benefits Modifications 1. Proposals for major retirement benefit modifications will be negotiated in joint meetings with the certified employee organizations whose memberships will be directly affected. Agreements reached between Management and organizations whereby a majority of the members in LACERS are affected shall be recommended to the City Council by the CAO as affecting the membership of all employees in LACERS. Such modifications need not be included in the MOU in order to be considered appropriately negotiated.
PROCEDURE FOR APPROVAL OF SETTLEMENT 28. Acceptance of this Settlement Agreement shall be sought at a hearing of the Central Regional Council of the MFDA on a date agreed to by counsel for Staff and the Respondent.
