Claim Disputes. Provider may, for a period of ninety (90) days from the receipt of payment of a claim, review the payment and provide to INSURER written notice of any perceived underpayment. INSURER shall reimburse Provider the amount of the underpayment within thirty (30) days provided documentation substantiates the payment error. After the ninety (90) day period has expired, payment of that claim is final and may not be disputed for any reason.
Claim Disputes. The result of the Covered Person claim dispute process shall be binding on Provider, per State Medicaid Grievance System requirements. For this Appendix, State Medicaid Grievance System means Arizona Administrative Code Title 9 Chapter 34 et. seq.
i) Provider may wish to file a claim dispute to maintain its regulatory afforded rights, e.g., based on a claim denial; for dissatisfaction with a claim payment; or for recoupment action by United. Provider may challenge the claim denial or adjudication by filing a formal claim dispute with United. Pursuant to AHCCCS guidelines and state rules, all claim disputes challenging claim payments, denials or recoupments must be filed in writing no later than 12 months from the date of services, 12 months after the date of eligibility posting or within 60 days after the payment, denial or recoupment of a timely claim submission, whichever is later. The claim dispute must be referenced/titled as such, i.e., “claim dispute” and state with particularity the factual and legal basis for the relief requested, along with all supporting documentation such as claims, remits, medical review sheets, medical records, correspondence, etc. Incomplete submissions or those which do not meet the criteria for a claim dispute will be denied.
ii) If Provider disagrees with the claim dispute decision at issue, Provider may submit its written request for a state fair hearing within 30 days of receipt of Provider’s claim dispute notice of decision (claim dispute at issue). Provider’s request for state fair hearing must include the claim dispute number from the notice of decision, the Covered Person’s name, and be clearly identified as a request for state fair hearing.
iii) All claim disputes must be submitted in writing in accordance with address listed on Provider’s remit from United and in applicable provider manual/administrative guide.
Claim Disputes. (a) Within thirty (30) days of its receipt of written notice from the Corporation under Section 8.5 above regarding a Corporation Claim and the amount of Corporation Group Damages related thereto, the Investors shall deliver to the Corporation written notice containing specific objections (prepared in good faith) to the nature of the Corporation Claim or the amount of Corporation Group Damages specified in the original notice. In such event, the Investors and the Corporation shall work in good faith during the next thirty (30) days toward resolving any such objections. If a resolution is reached within such thirty (30) days, the Corporation Group shall be indemnified for the amount so agreed upon in accordance with the other terms and conditions of this Agreement.
(b) Within thirty (30) days of its receipt of written notice from the Investors under Section 8.5 above regarding an Investor Claim and the amount of Investor Group Damages related thereto, the Corporation shall deliver to the Investors written notice containing specific objections (prepared in good faith) to the nature of the Investor Claim or the amount of Investor Group Damages specified in the original notice. In such event, the Corporation and the Investors shall work in good faith during the next thirty (30) days toward resolving any such objections. If a resolution is reached within such thirty (30) days, the Investor Group shall be indemnified for the amount so agreed upon in accordance with the other terms and conditions of this Agreement.
(c) In the event no mutually agreeable resolution of an indemnification matter is reached under the foregoing Sections 8.6(a) or 8.6(b) within such thirty (30) day period, such dispute shall be submitted to one arbitrator in accordance with the Rules of Commercial Arbitration of the American Arbitration Association. The arbitrator used will be selected from impartial arbitrators designated by the American Arbitration Association who are familiar with the nature of the subject matter of the Dispute. The arbitrator will be chosen by mutual agreement of the Corporation and the Investors. If they cannot agree within thirty (30) days upon the selection of the arbitrator, the arbitrator will be selected by the Dallas, Texas office of the American Arbitration Association in accordance with its rules and procedures. Subject to the provisions of the indemnification obligations set forth in this Agreement (i) each party will be responsible for one-half of the ex...
Claim Disputes. If a Tenant disputes a Claim, including after Claim payment has taken place, then the responsibility for resolving such a dispute will lie solely with Tenant and Company. Obligo will play no role in assessing the correctness or legality of any Claim, nor will it play a role in assessing the merit of Xxxxxx’s reason for dispute. Obligo will not be liable for any damages resulting from incorrect or illegal Claims, nor from unmerited disputes by Tenants. Obligo may, in its sole discretion, communicate with Company and Tenant regarding a Claim or a dispute, but in doing so would not be assuming any responsibility for the resolution of a dispute, nor liability for the outcome of the dispute. If a dispute is resolved in favor of a Tenant, then Company shall be responsible to refund the Claim or portion thereof to or for the account of Tenant.
Claim Disputes. Should you have a dispute concerning your premium or about a claim, you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. DISPUTAS POR XXXXXX DE SEGUROS O RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con la compañía primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas.
Claim Disputes. 25 SECTION 6.08 Remedies Exclusive.............................................26 ARTICLE VII
Claim Disputes. Provider may, for a period of 90 (ninety) days from the receipt of payment of a claim, review the payment and provide to INSURER written notice of any perceived underpayment. INSURER will reimburse Provider the amount of the underpayment within 30 (thirty) days provided documentation substantiates the payment error. After the 90 (ninety) day period has expired, payment of that claim is final and may not be disputed for any reason. This Agreement is effective upon the date of execution by USA. For and on behalf of: For and on behalf of: USA MANAGED CARE ORGANIZATION, INC. 000 Xxxxxxx xx Xxxxx Xxxxxxx Xxxxx Xxxxxx, Xxxxx 00000 Date Date Signature Signature Printed Name Printed Name Title Title
1. Provider agrees to provide health care service in conformity with accepted prevailing medical, surgical, chiropractic, physical therapy and mental health/substance abuse practices in the community in which Provider practices.
2. Provider agrees to utilize participating facilities, providers, and ancillary services (i.e., laboratory, x-ray, ultrasound, Xxxxxxx Tank, isokinetic equipment, etc.) when not available in Provider’s office and when consistent with good medical practice.
3. Provider agrees to perform pre-admission testing whenever INSURED is to be hospitalized.
4. Provider agrees to encourage the use of generic drugs, whenever medically possible, and when in the best interest of the patient.
5. Provider agrees not to xxxx separately for components of a procedure to increase reimbursement.
6. While Utilization Management is primarily conducted by telephone, certain situations may require an on- site visit. Should this occur, Provider agrees to accept Utilization Review Representatives on Provider’s office setting for the purpose of reviewing medical records pertinent to continued stay or retrospective review of INSURED. Utilization Review Representatives agree to conduct reviews in accordance with Provider's policies.
7. Provider agrees to promote and implement the aggressive treatment of an INSURED that will encourage the timely return to a quality standard of life as well as employment.
8. Provider agrees to follow treatment guidelines equivalent to those required by the state in which Provider provides services or as outlined by Provider’s specialty.
9. Provider agrees to ONLY provide those services actually necessary to effectively treat an INSURED and ONLY provide treatment that does not constitute “maintenance care”. Maintenance care is defined as treat...
Claim Disputes. (i) In the event that the Stockholder Representative delivers a written notice to Parent (a “Dispute Notice”) disputing all or any portion of the amount of the Determinable Losses (the “Disputed Claims Amount”) during the applicable Response Period, Parent and the Stockholder Representative shall for a period of not more than 30 days after delivery of such Dispute Notice (the “Resolution Period”) attempt to resolve the dispute. If the Disputed Claims Amount is less than the Determinable Losses claimed in the relevant Claim Notice, then Parent shall have the right to recover from the Stockholders the difference between (x) the Determinable Losses minus (y) the Disputed Claims Amount in accordance with Section 6.5.
(ii) If Parent and the Stockholder Representative do not resolve the dispute during the Resolution Period, either party may seek to resolve such dispute in a proceeding brought in any state or federal court located in the County of San Diego, California. During the Resolution Period, Parent and the Stockholder Representative shall provide each other with such information, records and material kept in the ordinary course of business in such party’s possession and which such party may disclose without violating confidentiality obligations to third Persons or any privilege, as is reasonably necessary and appropriate in attempting to resolve such Disputed Claims Amount determination, subject to execution of a confidentiality agreement in form and substance reasonably satisfactory to the delivering party.
(iii) In the event that the Final Determination (as defined below) is in favor of Parent with respect to all or a portion of a Disputed Claims Amount, after receipt of such Final Determination Parent shall have the right to recover from the Stockholders the that portion of the Disputed Claims Amount to which Parent is entitled pursuant to the Final Determination (“Payment Amount”) in accordance with Section 6.5. For purposes of this Agreement, the term “Final Determination” means either (i) instructions in writing executed by Parent and the Stockholder Representative or their respective legal representatives, or (ii) an order of a court or arbitrator that has become final and non-appealable.
Claim Disputes. 18 SECTION 9. EXPENSES.............................................................................................19 SECTION 10. NOTICES.............................................................................................19
Claim Disputes. A Claim Dispute is Subcontractor’s dispute of a payment, denial or recoupment of the payment of a claim, the imposition of a sanction, or the non-payment or partial payment of a performance incentive. All Claim Disputes shall be resolved according to requirements outlined in the ADHS Policy and Procedures Manual, GA 3.2 and ADHS/DBHS Provider Manual – Cenpatico Edition. Subcontractor may appeal a Cenpatico decision regarding a Claim Dispute in accordance with the ADHS/DBHS Provider Manual
