Appeal Services Sample Clauses

Appeal Services a. Contractor shall administer appeals in accordance with the appeals process described herein and as otherwise required by the Department and State and federal law. b. Contractor shall establish a Level I appeal process. The appeal process shall allow the Participant to supply any information or documentation to support the appeal. Contractor shall review the Level I appeal and all documentation and approve or deny the appeal. Upon determining that the Level I appeal is without merit, Contractor shall deny the Level I appeal in writing and provide a notification to the Member that the Member has an opportunity to file a Level II appeal with the Department. The Department will then handle all Level II appeals. Contractor shall assist the Department with Level II appeals and administrative hearings, as needed. c. The Department must approve and may customize any and all correspondence, letters, and other communications related to any part of the appeals process. Contractor shall adhere to the standards in Section 5: Performance Metrics of this Attachment 2. Contractor shall maintain a record of all grievances / appeals from Participants and shall provide a summary of grievances / appeals to the Department quarterly or more frequently, as requested. Upon request, Contractor shall provide a narrative summary of the reasons for the grievances / appeals, the disposition thereof, and any corrective action plans implemented as the result of the grievance / appeal. d. Upon the request of the Department or its attorneys, and within specified timeframes by the Department, Contractor shall provide all documentation related to a Participant's appeal / administrative hearings(s). This documentation shall include but not be limited to all documentation related to the Participant’s use of the HRA Program. Contractor shall make available the documentation and testimony of Contractor’s employees, consultants, associates, and other personnel necessary for the Department's presentation of the review or appeal / administrative hearings via telephone or in-person if required by the Department, at no cost to the Department.
Sample 1
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Appeal Services. At no additional cost, the Awarded Respondent shall administer appeals in accordance with the appeals process described in the Benefits Document and as otherwise specifically required by Department. Such appeals include Level I appeals, medical review/assistance to Department for Level II appeals/administrative hearings, and external reviews by the Awarded Respondent's Independent Review Organization (IRO). Any and all correspondence, letters, communications, etc. related to any part of the appeals process is subject to the customization and approval of Department. PGs 22-24.
Sample 1

Related to Appeal Services

  • Legal Services If this Agreement is for legal services, this section is applicable. Contractor shall: (i) adhere to legal cost and billing guidelines designated by the JBE; (ii) adhere to litigation plans designated by the JBE, if applicable; (iii) adhere to case phasing of activities designated by the JBE, if applicable; (iv) submit and adhere to legal budgets as designated by the JBE; (v) maintain legal malpractice insurance in an amount not less than the amount designated by the JBE; and (vi) submit to legal bill audits and law firm audits if so requested by the JBE, whether conducted by employees or designees of the JBE or by any legal cost-control provider retained by the JBE for that purpose. Contractor may be required to submit to a legal cost and utilization review as determined by the JBE. If (a) the Contract Amount is greater than $50,000, (b) the legal services are not the legal representation of low- or middle-income persons, in either civil, criminal, or administrative matters, and (c) the legal services are to be performed within California, then Contractor agrees to make a good faith effort to provide a minimum number of hours of pro xxxx legal services, or an equivalent amount of financial contributions to qualified legal services projects and support centers, as defined in section 6213 of the Business and Professions Code, during each year of the Agreement equal to the lesser of either (A) thirty (30) multiplied by the number of full time attorneys in the firm’s offices in California, with the number of hours prorated on an actual day basis for any period of less than a full year or (B) the number of hours equal to ten percent (10%) of the Contract Amount divided by the average billing rate of the firm. Failure to make a good faith effort may be cause for nonrenewal of this Agreement or another judicial branch or other state contract for legal services, and may be taken into account when determining the award of future contracts with a Judicial Branch Entity for legal services.

  • Hearing Services Hearing Exams and Tests Hearing Aids

  • Professional Services Bodily injury" or "property damage" arising out of the rendering of or failure to render profes- sional services;

  • Administration Services When a medical prescription drug is administered by infusion, the administration of the prescription drug may be covered separately from the prescription drug. See Infusion Therapy - Administration Services in the Summary of Medical Benefits for benefit limits and the amount you pay. Prescription drugs that are self-administered are not covered as a medical benefit but may be covered as a pharmacy benefit. Please see Pharmacy Prescription Drugs and Diabetic Equipment or Supplies – Pharmacy Benefits section above for additional information. For some medical prescription drugs, after the first administration, coverage may be limited to certain locations (for example, a designated outpatient or ambulatory service facility, physician’s office, or your home), provided the location is appropriate based on your medical status. For a list of medical prescription drugs that are subject to this Site of Care Program, visit our website. Preauthorization may be required to determine medical necessity as well as appropriate site of care. If we deny your request for preauthorization, or you disagree with our determination for the appropriate site of care, you can submit a medical appeal. See Appeals in Section 5 for information on how to file a medical appeal.

  • Municipal Services Commencing on the effective date of annexation, the City will provide the municipal services set forth below. As used in this Agreement, “providing services” includes having services provided by any method or means by which the City may extend municipal services to any other area of the City.

  • Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.

  • Medical Services Plan Regular Full-Time and Temporary Full-Time Employees shall be entitled to be covered under the Medical Services Plan commencing the first day of the calendar month following the date of employment. The City shall pay one hundred percent (100%) of the premiums required by the plan.

  • Special Services Should the Trust have occasion to request the Adviser to perform services not herein contemplated or to request the Adviser to arrange for the services of others, the Adviser will act for the Trust on behalf of the Fund upon request to the best of its ability, with compensation for the Adviser's services to be agreed upon with respect to each such occasion as it arises.

  • Provider Services Charges for the following Services when ordered by a Physician for the treatment of an Injury or Illness.

  • Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.

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