Claims and Appeals. The Contractor shall address claims for additional time or compensation under the Contract in writing to the Buyer and Project Manager within ten (10) Days of the date in which the Contractor knows or should know of the basis for the claim. Claims shall be accompanied by supporting documentation and citation to applicable provisions in the Contract documents. The County reserves the right to request additional documentation necessary to adequately review the claim. No claim by the Contractor shall be allowed if asserted after final payment under this Contract. The Buyer and Project Manager shall ordinarily respond to the Contractor in writing with a decision issued jointly, but absent such written response, the claim shall be deemed denied upon the tenth (10th) Day following receipt by the Buyer and Project Manager of the claim, or requested additional documentation, whichever is later. In the event the Contractor disagrees with the determination of the Buyer and Project Manager, the Contractor shall, within five (5) Days of the date of such determination, appeal the determination in writing to the Procurement and Payables Section Manager. Such written notice of appeal shall include all information necessary to substantiate the appeal. The Procurement and Payables Section Manager shall review the appeal and make a determination in writing, which shall be final. Appeal to the Procurement and Payables Section Manager on claims for additional time or compensation shall be a condition precedent to litigation. At all times, the Contractor shall proceed diligently with the performance of the Contract and in accordance with the direction of the Buyer or Project Manager. Failure to comply precisely with the time deadlines under this Section 8.1 as to any claim and appeal shall operate as a waiver and release of that claim and appeal and an acknowledgment of prejudice to the County.
Claims and Appeals. The Organization shall have the right to lodge a complaint on proceeding of the process defined in § 1 including the right to lodge a complaint regarding work of auditors. Complaints shall be lodged according to the procedure provided on the website xxx.xxxx.xxx.xx. The Organization shall have the right to submit an appeal against a decision of the PCBC. Appeals shall be lodged according to the procedure provided on the website xxx.xxxx.xxx.xx. The principle of impartiality and confidentiality shall be observed at all stages of proceeding in processing complaints/appeals.
Claims and Appeals. In the event of further developments, the UIPC may reconsider the VCR’s decision to retain intellectual property.
Claims and Appeals. The Plan has specific procedures for making a claim for benefits. You must exhaust this claim and appeal process before you can file a lawsuit in court. The claim and appeal process has two levels: (1) the initial claim and (2) review on appeal. They operate as follows:
Claims and Appeals. A. Delta Dental will adjudicate and process all clean Claims submitted for Contractor’s Dental Plan, in accordance with this Contract, the Certificate and Delta Dental’s standard operating procedures.
B. Subject to the terms of this Contract, Delta Dental has complete discretion to process Claims received under Contractor’s Dental Plan. As such, Delta Dental shall, without limitation, make determinations regarding:
1. Coordination of benefits.
2. The applicability of Benefit waiting periods, limitations and exclusions.
3. The quality of care provided to Plan Participants by a treating dentist; and
4. The appropriateness and/or necessity of services performed by a treating dentist.
C. Delta Dental shall provide Pre-Treatment Estimates to Plan Participants and Participating Dentists upon request as set forth in the Certificate. A Pre-Treatment Estimate is a voluntary and optional process where Delta Dental issues a written estimate of Benefits that may be available under the Dental Plan. A Pre-Treatment Estimate is not a prerequisite or condition for approval of future Benefits payment. Receipt of a Pre-Treatment Estimate does not guarantee payment or coverage, and is not a formal adjudication of a Claim. Pre-Treatment Estimates do not assess whether a Plan Participant is specifically eligible for a Covered Service or whether he or she has reached any applicable annual or lifetime maximum payments under the Dental Plan.
D. Delta Dental will follow established procedures for resolving all adverse Claims determination questions asserted by a dentist, Contractor, or Plan Participant as set forth in the Certificate (“Claims Appeal Procedure”). The Claims Appeal Procedure shall contain processes for appealing initial adverse determinations made by Delta Dental. To the extent the Dental Plan is governed by ERISA, Delta Dental’s procedures shall comply with ERISA and any regulations or guidelines thereunder. All determinations made according to the Claims Appeal Procedure will be final and binding on the Participating Dentist, the Contractor, and the Plan Participant; provided, however, that the Plan Participant may exercise any additional legal rights he or she may have.
E. Payments made directly to a Plan Participant as reimbursement for Covered Services under the Dental Plan are for the personal benefit of such Plan Participant and cannot be transferred or assigned. Delta Dental shall not honor attempts to assign Benefits unless required to by law.
F. Delta Dent...
Claims and Appeals. All required notifications to Plan participants regarding benefit determinations to be provided within the time limits set by ERISA and in accordance with the claims denial requirements set forth in the Supplemental Summary Plan Description (SSPD, “Claims Review Procedures”). 97% of member issues on written or oral claims to be documented with responses within 10 business days; all member issues on requests for full and fair reviews to be documented and sent to the BPO within 15 business days.
Claims and Appeals. The Seller will, upon the request of the Buyer, submit an appropriate claim to the Government, obtain a contracting officer decision or prosecute an appeal of any contracting officer decision with respect to any action taken or not taken by the Government under the Contract that in any way reduces or delays the payment of any Contract Payment or that, in the reasonable opinion of the Buyer, could adversely affect the Contract Payments.
Claims and Appeals. 1.2.1. Provider’s responsibilities with respect to coordination of benefits and third-party liability are stated in the Mercy Maricopa Provider Manual. In addition, as set forth in such manual, Provider agrees to identify Medicare and other third-party liability coverage and to seek such Medicare or third-party liability payment before submitting claims to the Company.
1.2.2. Providers must submit claims or encounters in conformance with Section 17.11 of the State Contract, the Mercy Maricopa Provider Manual, 6.2 Submitting Claims and Encounters to the RBHA, the ADHS/DBHS Office of Program Support Operations and Procedures Manual, the ADHS/DBHS Covered Behavioral Health Services Guide, the ADHS/DBHS Financial Reporting Guide for GSA 6, the Client Information System (CIS) File Layouts and Specifications Manual requirements and in accordance with HIPAA for each covered service delivered to a Member.
1.2.3. Provider shall utilize electronic transactions to ensure inter-operability and transmission compatibility across management information systems.
1.2.4. Provider shall appeal a claim denial in accordance with this Agreement, Company’s Policies, and the Mercy Maricopa Provider Manual, 5.6,
Claims and Appeals. Participants may submit claims for benefits by giving notice to the Company pursuant to Section 9 of this Policy. If a Participant believes that he or she has not received coverage or benefits to which he or she is entitled under the Policy, the Participant may notify the Board in writing of a claim for coverage or benefits. If the claim for coverage or benefits is denied in whole or in part, the Board shall notify the applicant in writing of such denial within thirty (30) days (which may be extended to sixty (60) days under special circumstances), with such notice setting forth: (i) the specific reasons for the denial; (ii) the Policy provisions upon which the denial is based; (iii) any additional material or information necessary for the applicant to perfect his or her claim; and (iv) the procedures for requesting a review of the denial. Upon a denial of a claim by the Board, the Participant may: (i) request a review of the denial by the Board or, where review authority has been so delegated, by such other person or entity as may be designated by the Board for this purpose; (ii) review any Policy documents relevant to his or her claim; and (iii) submit issues and comments to the Board or its delegate that are relevant to the review. Any request for review must be made in writing and received by the Board or its delegate within sixty (60) days of the date the applicant received notice of the initial denial, unless special circumstances require an extension of time for processing. The Board or its delegate will make a written ruling on the applicant’s request for review setting forth the reasons for the decision and the Policy provisions upon which the denial, if appropriate, is based. This written ruling shall be made within thirty (30) days of the date the Board or its delegate receives the applicant’s request for review unless special circumstances require an extension of time for processing, in which case a decision will be rendered as soon as possible, but not later than sixty (60) days after receipt of the request for review. All extensions of time permitted by this Section 16 will be permitted at the sole discretion of the Board or its delegate. If the Board does not provide the Participant with written notice of the denial of his or her appeal, the Participant’s claim shall be deemed denied.
Claims and Appeals. In the event a Participant or Beneficiary believes he or she is entitled to a payment from the Company which has not been made, he or she may submit a claim for benefits to the Administrative Committee. Any denial of the claim shall be made by the Administrative Committee in writing and shall specify the Plan provisions upon which the denial is based and any additional information or documentation which the Participant would need to submit to perfect his or her claim. The Participant may appeal in writing to the Administrative Committee any denial of his or her claim within 90 days following the denial, and shall include any additional information or documentation helpful to support his or her claim. The Administrative Committee's decision shall be made in writing within 90 days of receipt of the appeal and shall be final and binding on the Participant and the Company.
