Claim Appeals Sample Clauses

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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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Related to Claim Appeals

  • 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: Chief Procurement Officer Procurement Services A Division of the Office of General Services 00xx Xxxxx, Xxxxxxx Xxxxx Xxxxxx Xxxxx Xxxxx Xxxxxx, XX 00000 Email: xxxxxxxx.xxxxxxxx@xxx.xx.xxx Subject line: Appeal – Attn: Chief Procurement Officer

  • Claim Procedure Any Person entitled to indemnification hereunder shall (i) give prompt written notice to the indemnifying party of any claim with respect to which it seeks indemnification (provided that the failure to give prompt notice shall impair any Person’s right to indemnification hereunder only to the extent such failure has prejudiced the indemnifying party) and (ii) unless in such indemnified party’s reasonable judgment a conflict of interest between such indemnified and indemnifying parties may exist with respect to such claim, permit such indemnifying party to assume the defense of such claim with counsel reasonably satisfactory to the indemnified party. If such defense is assumed, the indemnifying party shall not be subject to any liability for any settlement made by the indemnified party without its consent (but such consent shall not be unreasonably withheld, conditioned or delayed). An indemnifying party who is not entitled to, or elects not to, assume the defense of a claim shall not be obligated to pay the fees and expenses of more than one counsel for all parties indemnified by such indemnifying party with respect to such claim, unless in the reasonable judgment of any indemnified party a conflict of interest may exist between such indemnified party and any other of such indemnified parties with respect to such claim. In such instance, the conflicted indemnified parties shall have a right to retain one separate counsel, chosen by the Holders representing a majority of the Registrable Securities included in the registration if such Holders are indemnified parties, at the expense of the indemnifying party.

  • 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.

  • Claims Administration An employee will be required to comply with any and all rules and regulations and/or limitations established by the carrier or applicable third party administrator and contained in the policy, and employees and their dependents shall look solely to such carrier or third party administration for the adjudication of the payment of any and all benefits claims.

  • Claims Procedure Any person who has not received benefits under this Agreement that he or she believes should be paid (the “claimant”) shall make a claim for benefits as follows.

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