Claim Appeals. Appeals will be reviewed with a new full and fair review. If the denial reason was due to medical necessity or experimental/investigational rationale, the appeal will be reviewed by a qualified Physician who had no involvement in the initial review or any prior reviews. If, pursuant to such review, the clinical decision is upheld, then the Covered Person may have the right to seek Independent External Review. The decision of the independent review organization (“IRO”) will be final and binding.
Claim Appeals. As of the Closing Time, OMNOVA shall have sole responsibility for the determination of claim appeals filed by OMNOVA Employees under the OMNOVA Medical Plan. Claim appeals filed by employees of OMNOVA under the GenCorp Medical Plan will be determined by GenCorp under the GenCorp Medical Plan.
Claim Appeals. In the event of a claim denial by PBM, PBM shall promptly communicate to the Covered Person the right to appeal according to the Covered Person's Benefit Contract and Pharmacy Rider and applicable law.
Claim Appeals. Any complaint or grievance regarding the amount of a payment or non-payment hereunder shall be submitted by Participating Provider in writing to QualCare or the applicable Payor within twelve (12) months of the receipt of such payment or receipt of the denial of such payment. If no complaint or grievance has been received by QualCare or the applicable Payor within such twelve (12) month period, the payment or non-payment shall be considered final, and Participating Provider shall forfeit any right to contest such payment or non-payment.
Claim Appeals. (a) In the event that PORI makes only partial payment or denies payment of a Clean Claim, Provider may appeal the decision by sending a letter marked "Appeal Request" to the Accounts Payable Department at PORI. Such letter shall contain the following information: Provider name, date of service, date of billing, date of partial payment or payment denial, and the reason(s) the claim merits consideration. The appeal must be submitted to PORI within sixty (60) days of the date of partial payment or denial. Appeals submitted after the sixty (60) day limit shall be considered null and void.
(b) If PORI fails to act on the appeal request within forty-five (45) days of its receipt, or if the Provider does not agree with PORI's appeal decision, the Provider may appeal to DHS. The appeal must be submitted to DHS within sixty (60) days of PORI's appeal decision. The DHS decision is final. If DHS finds in favor of the Provider, PORI will pay the Provider within thirty (30) days of receipt of DHS’s final decision.
(c) In the event of any dispute arising from any claim submitted by the Provider, each party shall have access to all reasonable and necessary documents and records that would, at the discretion of each party, tend to sustain its claim (subject to applicable laws and regulations).
Claim Appeals. As of the Closing Time, Omnova shall have sole responsibility for the determination of claim appeals filed by Omnova Employees under the Omnova Medical Plan. Claim appeals filed by employees of Omnova under the GenCorp Medical Plan will be determined by GenCorp under the GenCorp Medical Plan.
Claim Appeals. As of the Effective Date, the REX Xxxical Plan shall have sole responsibility for the determination of claim appeals filed by REX Xxxloyees under the REX Xxxical Plan. Claim appeals filed by employees of REX xxxer the RSI Medical Plan will be determined by the RSI Medical Plan.
Claim Appeals. In the event that PORI makes only partial payment or denies payment of a Clean Claim, Hospital may appeal the decision by sending a letter marked "Appeal Request" to the Accounts Payable Department at PORI. Such letter shall contain the following information: Hospital name, date of service, date of billing, date of partial payment or payment denial, and the reason(s) the claim merits consideration. The appeal must be submitted to PORI within sixty (60) days of the date of partial payment or denial. Appeals submitted after the sixty (60) day limit shall be considered null and void. PORI will contact the Hospital with an appeal decision within forty five (45) days. If at that time, Hospital does not agree with PORI's appeal decision, the Hospital may appeal to DHS. The appeal must be submitted to DHS within sixty (60) days of PORI's appeal decision. The DHS decision is final. If DHS finds in favor of the Hospital, PORI will pay the Hospital within thirty (30) days of receipt of DHS's final decision. In the event of any dispute arising from any claim submitted by the Hospital, each party shall have access to all reasonable and necessary documents and records that would, at the discretion of each party, tend to sustain its claim (subject to applicable laws and regulations).
