Adverse Benefit Determination An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.
Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:
Proposing Integration Activities in the Planning Submission No integration activity described in section 6.3 may be proposed in a CAPS unless the LHIN has consented, in writing, to its inclusion pursuant to the process set out in section 6.3(b).
DISQUALIFICATION FOR PAST PERFORMANCE AND FINDINGS OF NON RESPONSIBILITY Bidder may be disqualified from receiving awards if Bidder, or anyone in Bidder’s employment, has previously failed to perform satisfactorily in connection with public Bidding or contracts or is deemed non- responsible.
Procedures Related to Indemnification In the event that an indemnity obligation arises, Vendor shall pay all amounts set forth in Section 14 and 15 above (including any settlements) and – if it has accepted its indemnity obligation without qualification – control the legal defense to such claim or cause of action, including without limitation attorney selection, strategy, discovery, trial, appeal, and settlement, and TIPS shall, at Vendor’s cost and expense (with respect to reasonable out of pocket costs and expenses incurred by TIPS which shall be reimbursed to TIPS by Vendor), provide all commercially reasonable assistance requested by Vendor. In controlling any defense, Vendor shall ensure that all assertions of governmental immunity and all applicable pleas and defenses shall be promptly asserted.
Liability Calculation Method Per Claim Unless subject to a fixed dollar copayment, the calculation of Member liability on claims for Out-of-Area Covered Health Care Services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Blue Shield by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s health care provider contracts. The negotiated price made available to Blue Shield by the Host Blue may be represented by one of the following:
FLORIDA CONVICTED/SUSPENDED/DISCRIMINATORY COMPLAINTS By submission of an offer, the respondent affirms that it is not currently listed in the Florida Department of Management Services Convicted/Suspended/Discriminatory Complaint Vendor List.
Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.
Salary Determination 12.5.1 A unit member shall receive a salary not less than the minimum salary nor more than the maximum salary (Articles 12.3 and 12.4) for the rank to which appointed, except as provided in Articles 4.15, 5.6, 10.6.1 or Article 10.6.1.1. The effective dates for salaries shall be the appropriate dates specified in Article 12.2.2.
Claims Review Findings a. Narrative Results.
