Common use of Complaint and Administrative Appeal Procedures Clause in Contracts

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because: • the services were excluded from coverage; • we failed to make payment (in whole or part) for a service; • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred); • you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or • other limitation on an otherwise covered benefit.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because: •  the services were excluded from coverage; •  we failed to make payment (in whole or part) for a service; •  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred); •  you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or •  other limitation on an otherwise covered benefit.