Beneficiary Appeals and/or Grievances Sample Clauses

Beneficiary Appeals and/or Grievances. Beneficiaries retain their rights to appeal claims determinations in accordance with the terms of the DVHA Member Handbook and Participant and Preferred Provider remain bound by the terms of the DVHA General Provider Agreement as to Beneficiary grievances and appeals. Participant and Preferred Provider will direct all appeals and/or grievances or payment disputes related to this Program to ACO and ACO will manage them in accordance with an ACO Appeals Policy that complies with Program requirements. The appeals policy includes a written initial appeal and a second level of appeal with the opportunity to be heard in person. Participant and Preferred Provider will continue to cooperate with DVHA in the resolution of Beneficiary grievances and disputes.
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Beneficiary Appeals and/or Grievances. Beneficiaries/Members retain their rights to appeal claims determinations in accordance with the terms of their benefit policies and Participant and Preferred Provider remain bound by the terms of their BCBSVT provider agreements as to Beneficiary/Member grievances and appeals.
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Beneficiary Appeals and/or Grievances. Beneficiaries retain their rights to appeal claims determinations in accordance with 42 C.F.R. § 405, Subpart I. Participant and Preferred Provider will direct all appeals and/or grievances or payment disputes, related to this Program, to ACO and ACO will manage them in accordance with an ACO Appeals Policy that complies with Program requirements. Participant and Preferred Provider will continue to cooperate with CMS in the resolution of an Attributed Beneficiary’s appeal or grievance.
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Beneficiary Appeals and/or Grievances. MVP Beneficiaries/Members retain their rights to appeal claims determinations in accordance with the terms of their benefit policies and Participants and Preferred Providers remain bound by the terms of their MVP provider agreements and applicable law as to Plan Beneficiary/Member grievances and appeals.
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Beneficiary Appeals and/or Grievances. BCBSVT Primary Program Attributed Lives retain their rights to appeal claims determinations in accordance with the terms of their benefit policies and Participants and Preferred Providers remain bound by the terms of their BCBSVT provider agreements as to member grievances and appeals.
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Related to Beneficiary Appeals and/or Grievances

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • Employer Grievance The Employer may institute a grievance by delivering the same in writing to the President of the Local Union and the President shall answer such grievance in writing within five working (5) days. If the answer is not acceptable to the Employer, the Employer may, within ten (10) working days from the day the President gives her answer, give ten (10) working days notice to the President of the Local Union of its intention to refer the dispute to arbitration.

  • Administrative Appeals An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

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