BOH Appeals Sample Clauses

BOH Appeals. If, on internal Appeal, the Contractor does not decide fully in the Enrollees’ favor, and the Appeal concerns a Medicaid covered service, the Contractor shall: 1. Require Enrollees and their Appeal Representatives to exhaust the Contractor’s Internal Appeals process before filing an appeal with the Board of Hearings (BOH). The exhaustion requirement is satisfied if either of the following conditions is met: a. The Contractor has issued a decision following its review of the Adverse Action; or b. The Contractor fails to act within the timeframes for reviewing Internal Appeals or fails to satisfy applicable notice requirements; 2. Include with any notice following the resolution of an Internal Appeal any and all instructive materials and forms provided to the Contractor by EOHHS that are required for the Enrollee to request a BOH Appeal; and 3. Notify Enrollees that: a. Any Continuing Services being provided by the Contractor that are the subject of a BOH Appeal will continue, unless the Enrollee specifically indicates that he or she does not want to receive Continuing Services and that the Enrollee may be required by EOHHS to pay the cost of services furnished while a BOH Appeal is pending, if the final decision is adverse to the Enrollee; and b. It is the Enrollee’s or the Appeal Representative’s responsibility to submit any request for a BOH Appeal to the BOH and to ensure that the BOH receives the request within the following time limits, as specified in 130 CMR 610.015(B)(7): 1) For BOH Appeals of a standard Internal Appeal resolved by the Contractor within the timeframes specified in Section 2.8.D.1.b, 30 calendar days after the notice following the Internal Appeal, as specified in Section 2.8.D.3; 2) For BOH Appeals of a standard Internal Appeal resolved by the Contractor within the timeframes specified in Section 2.8.D.1.b, in which the Enrollee wants to continue receiving the services that are the subject of the BOH Appeal, 10 calendar days after the notice following the Internal Appeal, as specified in Section 2.8.D.3; 3) For BOH Appeals of an expedited Internal Appeal resolved by the Contractor within the timeframe specified in Section 2.8.D.1.c, 20 calendar days after the notice following the Internal Appeal, as specified in Section 2.8.D.3, or within 30 calendar days in which case the BOH Appeal will be treated as a non-expedited (i.e., standard) BOH Appeal request; 4) For BOH Appeals of a standard Internal Appeal not resolved by the Contractor ...
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Related to BOH Appeals

  • Legal Appeals a. Nothing contained in these provisions is intended to limit or impair the rights of any vendor or Contractor to seek and pursue remedies of law through the judicial process. Appendix C, Contract Modification Procedure, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. Appendix D, Pricing Schedules, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. The Parties expressly agree that these prices are established as “maximum Not-To-Exceed prices”. The Contractor acknowledges that any mini-bid under this Centralized Contract which includes pricing in excess of the “maximum Not-To-Exceed price” shall be rejected by the Authorized User. Amendments to Appendix D, Pricing Schedules, shall be processed in accordance with Appendix C, Contract Modification Procedure, section 4.8, OGS Centralized Contract Modifications and section 4.23 Price Adjustments for OGS Centralized Contracts. Appendix E, Report of Contract Purchases, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. OGS reserves the right to make unilateral changes to this Report of Contract Purchases document. Appendix F, Project Based Information Technology Consulting Services Processes and Forms, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. OGS reserves the right to change the processes and forms set forth Appendix F in non-material and substantive ways without seeking a contract amendment. Appendix F is comprised of the following attachments: a. Attachment 1- Mini-Bid Template b. Attachment 2- How to Use This Contract c. Attachment 3- Enhancement Request Template d. Attachment 4- No Cost Change Request Template e. Attachment 5- Mini-Bid Participation Interest Template Appendix G, Contractor and OGS Information, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. The Parties agree that the elements identified in 4.7.1 below, OGS Designated Contact information, and information regarding Procurement Card acceptance as presented in Appendix G can be updated without the Parties engaging in a formal contract amendment. All other changes must be handled through the Contract Modification Process or a formal contract amendment.

  • Appeals a. Should the filer be dissatisfied with the Formal Dispute determination, a written appeal may be filed with the Chief Procurement Officer, by mail or email, using the following contact information: 00xx Xxxxx, Xxxxxxx Xxxxx Xxxxxx Xxxxx Xxxxx Xxxxxx, XX 00000 Email: xxxxxxxx.xxxxxxxx@xxx.xx.xxx Subject line: Appeal – Attn: Chief Procurement Officer b. Written notice of appeal of a determination must be received at the above address no more than ten (10) business days after the date the decision is received by the filer. The decision of the Director of Procurement Services shall be a final and conclusive agency determination unless appealed to the Chief Procurement Officer within such time period. c. The Chief Procurement Officer shall hear and make a final determination on all appeals or may designate a person or persons to act on his/her behalf. The final determination on the appeal shall be issued within twenty (20) business days of receipt of the appeal. d. An appeal of the decision of the Director of Procurement Services shall not include new facts and information unless requested in writing by the Chief Procurement Officer. e. The decision of the Chief Procurement Officer shall be a final and conclusive agency determination.

  • 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.

  • Disciplinary Appeals All forms of disciplinary action which are not appealable to the Civil Service Commission or the courts, except written or oral reprimands and Forms 475, shall be subject to review through Steps 3, 4, 5 and 6 of the grievance procedure.

  • Arbitration Appeal A. If an employee grievance is not resolved at Step 2, the aggrieved employee or the PBA may, within fifteen (15) calendar days after receipt of the Step 2 response, submit a request for arbitration to the Labor Relations Office. B. In non-disciplinary grievances, either the PBA or the Employer may request to take the issue or grievance directly to arbitration by submitting the request for arbitration to the Labor Relations Office. C. If the parties fail to mutually agree upon an arbitrator within five (5) calendar days after the date of receipt of the arbitration request, a list of seven (7) qualified neutrals shall be requested and paid for by the moving party from the Federal Mediation and Conciliation Service (FMCS). Within fifteen (15) calendar days after receipt of the list, the parties shall meet and alternately strike names on the list, and the remaining name shall be the arbitrator. A coin shall be tossed to determine who shall strike first. Each party has the right to reject one list. The party rejecting the list shall be responsible for paying for and obtaining the next list and the above described procedures will be followed for selection from the list. If the selected arbitrator is not available for a hearing within ninety (90) days of the date the arbitrator was selected, another list may be requested by the Labor Relations Office, which will pay the fee for that particular list. If the grievant is not represented by the Union, the list of arbitrators shall be requested from the American Arbitration Association with the moving party paying whatever fees may be charged. Once a list has been obtained, the procedures detailed above shall be used for selecting an arbitrator. D. The hearing on the grievance shall be informal and the rules of evidence shall not apply; however, to assure an orderly hearing, the rules of judicial procedure should be followed as closely as possible.

  • SCHOOL ACT APPEALS 1 Where a pupil and/or parent/guardian files an appeal under the School Act and Board By-law of a decision of an employee covered by this Agreement: a. the employee and the Association shall immediately be notified of the appeal, and shall be entitled to receive all documents relating to the appeal; b. the employee shall have a right to be present, and/or to have union representation at the hearing of the Appeal Committee; and c. the employee shall have the opportunity to provide a written submission with respect to the appeal.

  • Review and Appeal 1. Each Party shall ensure that the importers in its territory have access to administrative review within the customs administration that issued the decision subject to review or, where applicable, the higher authority supervising the administration and/or judicial review of the determination taken at the final level of administrative review, in accordance with the Party's domestic law. 2. The decision on appeal shall be given to the appellant and the reasons for such decision shall be provided in writing. 3. The level of administrative review may include any authority supervising the customs administration of a Party.

  • 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.

  • Complaints and Appeals As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

  • Grievances and Appeals a. If you have questions about any pediatric dental services received, please first discuss the matter with your Dental Provider. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center. You can also email questions by accessing the “Contact Us” section of the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.

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