Common use of Claim Grievance Procedure Clause in Contracts

Claim Grievance Procedure. Any dispute about BENEFITS or claims arising under the terms, conditions, and provisions of this AGREEMENT shall first be submitted for resolution through WPS’ internal grievance process and may then, if necessary be submitted to the DEPARTMENT. The PARTICIPANT may file a complaint with the Quality Assurance Services Bureau for review. The PARTICIPANT may also request a departmental determination. The determination of the DEPARTMENT is final and not subject to further review unless a timely appeal of the determination by the DEPARTMENT is submitted to the BOARD, as provided by Wis. Stat. § 40.03 (6) (i.) and Wis. Admin. Code § ETF 11.01 (3). The decision of the BOARD is reviewable only as provided in Wis. Stat. § 40.08 (12). If any PARTICIPANT has a problem or complaint relating to a determination of BENEFITS, he/she should contact WPS. WPS shall assist the PARTICIPANT in trying to resolve the matter on an informal basis, and may initiate a claim review of the BENEFITS determination. If the PARTICIPANT wishes, he/she may omit this step and immediately file a formal grievance. Written inquiries received by WPS not related to BENEFITS determinations shall be resolved by WPS within an average of twelve (12) DAYS following WPS’ receipt of the inquiry.

Appears in 3 contracts

Samples: Professional Administrative Services Only Agreement, Professional Administrative Services Only Agreement, Administrative Services Only Agreement

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Claim Grievance Procedure. Any dispute about BENEFITS or claims arising under the terms, conditions, and provisions of this AGREEMENT shall first be submitted for resolution through WPS’ internal grievance process and may then, if necessary be submitted to the DEPARTMENT. The PARTICIPANT may file a complaint with the Quality Assurance Services Bureau for review. The PARTICIPANT may also request a departmental determination. The determination of the DEPARTMENT is final and not subject to further review unless a timely appeal of the determination by the DEPARTMENT is submitted to the BOARD, as provided by Wis. Stat. § 40.03 (6) (i.) and Wis. Admin. Code § ETF 11.01 (3). The decision of the BOARD is reviewable only as provided in Wis. Stat. § 40.08 (12). If any PARTICIPANT has a problem or complaint relating to a determination of BENEFITS, he/she should contact WPS. WPS shall assist the PARTICIPANT in trying to resolve the matter on an informal basis, and may initiate a claim review of the BENEFITS determination. If the PARTICIPANT wishes, he/she may omit this step and immediately file a formal grievance. Written inquiries received by WPS not related to BENEFITS determinations shall be resolved by WPS within an average of twelve (12) DAYS following WPS’ receipt of the inquiry.

Appears in 1 contract

Samples: Administrative Services Only Agreement

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