Complaint system Sample Clauses

Complaint system. Every prepaid limited health service organization shall establish and maintain a complaint system providing reasonable procedures for resolving written complaints initiated by enrollees and providers. Nothing herein may be construed to preclude an enrollee or a provider from filing a complaint with the commissioner or as limiting the commissioner's ability to investigate such complaints.
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Complaint system. The Contractor’s PIU shall operate a system to receive, investigate and track the status of Fraud, Waste and Abuse complaints from Members, Providers and all other sources which may be made against the Contractor, Providers or Members. The system shall contain the following: (a) Upon receipt of a complaint or other indication of potential Fraud or Abuse, the Contractor’s PIU shall conduct a preliminary inquiry to determine the validity of the complaint; (b) The PIU should review background information and MIS data; however, the preliminary inquiry shall not include interviews with the subject concerning the alleged instance of Fraud or Abuse; (c) If the preliminary inquiry results in a reasonable belief that the complaint does not constitute Fraud or Abuse, the PIU should not refer the case to OIG; however, the PIU shall take whatever remedial actions may be necessary, up to and including administrative recovery of identified overpayments; (d) If the preliminary inquiry results in a reasonable belief that Fraud or Abuse has occurred, the PIU shall refer the case and all supporting documentation to the OIG, with a copy to the Department; (e) The OIG will review the referral and attached documentation, make a determination and notify the PIU as to whether the OIG will investigate the case or return it to the PIU for appropriate administrative action; (f) If, in the process of conducting a preliminary review, the PIU suspects a violation of either criminal Medicaid Fraud statutes or the Federal False Claims Act, the PIU shall immediately notify the OIG with a copy to the Department of their findings and proceed only in accordance with instructions received from the OIG; (g) If the OIG determines that it will keep a case referred by the PIU, the OIG will conduct a preliminary investigation, gather evidence, write a report and forward information to the Department, the PIU, or, if warranted, to the Attorney General’s Medicaid Fraud Control Unit, for appropriate actions; (h) If the OIG opens an investigation based on a complaint received from a source other than the Contractor, the OIG will, upon completion of the preliminary investigation, provide a copy of the investigative report to the Department, the PIU, or if warranted, to MFCU, for appropriate actions; (i) If the OIG investigation results in a referral to the MFCU and/or the U.S. Attorney, the OIG will notify the Department and the PIU of the referral. The Department and the PIU shall only take actions c...
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Complaint system. The insured has the right to submit a complaint not related with an adverse determination and a review of a complaint related with an adverse determination in accordance with Law No. 194 of August 25, 2000, Bill of Rights and Responsibilities of the Patient, Law No. 161 of November 1, 2010 to amend Art. 2 and 7 of Law No. 194 of 2000 and in accordance with the Patient Protection and Affordable Care Act 75 Fed. Reg. 43330-43364 (July 23, 2010). In case in which the insured has a complaint or doubt on the benefits of the coverage, he or she may submit a claim by visiting or calling our Customer Service Department or visiting one of our Service Centers located throughout the Island, where the complaint will be carefully taken care of and all the necessary measures will be taken to solve the issue in the most efficient and rapid way possible. There is also a complaint and appeals procedure which warrants the insureds the right to submittal, of efficiently investigating the complaint and the prompt and timely decision of complaints and appeals; as our purpose is that our insureds are satisfied with the service being offered and to achieve that the rights and responsibilities of those involved are respected. In addition, this procedure warrants the confidentiality between the parts. The insured or his or her personal representative (family, friend, counsel), by written consent may submit a claim or complaint. In addition, the following persons or entities may submit a claim or complaint on behalf of the insured: The health service provider through written consent; Persons authorized by court or according to state laws to act on behalf of the insured; A representative assigned by the state on behalf of a deceased insured. Staff of a government agency, like the Office of the Insurance Commissioner, the Office of the Health Ombudsman, House of Representatives, the Senate, Office of the Citizen Ombudsman, and the Office of the Governor. MCS Life will confirm that the person submitting the complaint is the personal representative assigned by the insured by calling the insured or by means of any provided written documentation. If MCS Life cannot confirm representation, a letter will be sent to the insured notifying that his or her case will not be processed until the information has been received.
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Related to Complaint system

  • Complaints If you have a complaint relating to the sale of energy by us to you, or this contract generally, you may lodge a complaint with us in accordance with our standard complaints and dispute resolution procedures. Note: Our standard complaints and dispute resolution procedures are published on our website.

  • COMPLAINT PROCEDURES CONTRACTOR shall maintain and adhere to its written procedures for responding to parent complaints. These procedures shall include annually notifying and providing parents of LEA students with appropriate information (including complaint forms) for the following: (1) Uniform Complaint Procedures pursuant to Title 5 of the California Code of Regulations section 4600 et seq.; (2) Nondiscrimination policy pursuant to Title 5 of the California Code of Regulations section 4960 (a); (3) Sexual Harassment Policy, California Education Code 231.5 (a) (b) (c); (4) Title IX Pupil Grievance Procedure, Title IX 106.8 (a) (d) and 106.9 (a); and (5) Notice of Privacy Practices in compliance with Health Insurance Portability and Accountability Act (HIPAA), if applicable. CONTRACTOR shall include verification of these procedures to the LEA upon request. CONTRACTOR shall immediately notify LEA of any complaints filed against it related to LEA students and provide LEA with all documentation related to the complaints and/or its investigation of complaints, including any and all reports generated as a result of an investigation.

  • Customer Complaints Each party hereby agrees to promptly provide to the other party copies of any written or otherwise documented complaints from customers of Dealer received by such party relating in any way to the Offering (including, but not limited to, the manner in which the Shares are offered by the Dealer Manager or Dealer), the Shares or the Company.

  • Product Complaints Subdistributor shall promptly notify Distributor of (but in no event later than 24 hours after receipt), and provide, upon Distributor’s request, reasonable assistance to address and investigate, any complaint or adverse claim about any Product or its use of which Subdistributor becomes aware;

  • Processing of a Grievance It is recognized and accepted by the Union and the Employer that the processing of grievances as hereinafter provided is limited by the job duties and responsibilities of the employees and shall therefore be accomplished during normal working hours only when consistent with such employee duties and responsibilities. The aggrieved employee and a Union representative shall be allowed a reasonable amount of time without loss of pay when a grievance is investigated and presented to the Employer during normal working hours provided that the employee and the Union representative have notified and received the approval of the designated supervisor who has determined that such absence is reasonable and would not be detrimental to the work programs of the Employer.

  • Complaints Process The School shall establish and adhere to a process for resolving public complaints which shall include an opportunity for complainants to be heard. The final administrative appeal shall be heard by the School's Governing Board, except where the complaint pertains to a possible violation of any law or term under this Contract. The complaints process shall be readily accessible from the School’s website, as described in Section 11.4.1.

  • COMPLAINT AND GRIEVANCE PROCEDURE 9.01 Where a difference arises between the parties relating to the interpretation, application or administration of this Agreement, including any questions as to whether a matter is arbitrable, or where an allegation is made that this Agreement has been violated or whenever an employee who has completed the required probationary period and has been accepted by the Employer for employment in the permanent service, claims that he/she has been disciplined or discharged without reasonable cause, such difference, allegation or claim being hereinafter referred to as the grievance, the grievance procedure set forth below shall apply. 9.02 The Association shall name, appoint or otherwise select a Grievance Committee of no more than three (3) who shall be members of the Association and shall have reached at least the rank of First Class Fire Fighter and other advisors as deemed necessary at the expense of the Association. The Employer shall recognize and deal with the Grievance committee with respect to any matter or dispute which properly arises from a breach of the Collective Agreement from time to time during its term. This committee shall suffer no loss as a result of their attendance at such grievance meetings, hearings, etc. 9.03 No grievance will be considered where the circumstances giving rise to it occurred or originated more than ten (10) full working days before the submission of the grievance. Step 1 - An employee having a grievance will take the matter up through their Association representative. The President or designate shall contact Fire Management to seek a resolution. Step 2 - If the grievance is not settled within five (5) working days, the Association shall submit the matter in writing to the Fire Chief or designate within five (5) working days of receiving the reply from Step 1. The Fire Chief or designate shall render the written decision to the Association within five (5) working days after receiving the written grievance. In the context of this Article a working day shall be deemed to be Monday to Friday excluding designated holidays. Step 3 - If the reply of the Fire Chief is not acceptable to the Association the grievance may be referred to the Chief Administrative Officer (CAO) or the Director of Human Resources within five (5) working days of the written decision of the Fire Chief. The CAO or the Director of Human Resources, who together with the Fire Chief and any other advisors deemed necessary, shall meet with the Association Representatives within 5 working days to consider the grievance. Within five (5) working days of the aforesaid, the CAO or the Director of Human Resources will render a written reply to the employee and the Association. Step 4 - If no resolve is reached at Step 3, the matter shall be submitted to arbitration. Notice shall be given within 5 business days. The parties agree that, for the purposes of this collective agreement the words of the expedited arbitration provisions of the Labour Relations Act, 1995 as amended (Section 49), will be deemed to have been incorporated into this collective agreement. Accordingly and notwithstanding any other provisions of this article (the grievance/arbitration provisions); either party may refer a grievance to expedited arbitration in accordance with the provisions of Section 49. The parties further agree that neither party will raise any jurisdictional or other objection to the application of Section 49 to a grievance under this collective agreement as it pertains to the right to an expedited arbitration. Either party is entitled however, to raise any objection, with the arbitrator with respect to whether the provisions of Section 49 have been properly utilized in respect of any specific grievance (e.g. objections with respect to time limits etc.). Such an appointment by the Minister of Labour or his or her designate will be determined to be a joint appointment in accordance with Section 53(3) of the Fire Protection and Prevention Act. 9.04 Extensions to the time limits in 9.03 may not be unreasonably withheld. 9.05 The employee in all steps of the grievance procedure shall be confined to the grievance and redress sought as set forth in the written grievance initially filed as provided.

  • COMPLAINTS HANDLING 44.1 Either Party shall notify the other Party of any Complaints made by Other Contracting Bodies, which are not resolved by operation of the Supplier's usual complaints handling procedure within five (5) Working Days of becoming aware of that Complaint and, if the Supplier is the Party providing the notice, such notice shall contain full details of the Supplier's plans to resolve such Complaint. 44.2 Without prejudice to any rights and remedies that a complainant may have at Law (including under this Framework Agreement and/or a Call Off Agreement), and without prejudice to any obligation of the Supplier to take remedial action under the provisions of this Framework Agreement and/or a Call Off Agreement, the Supplier shall use its all reasonable endeavours to resolve the Complaint within ten (10) Working Days and in so doing, shall deal with the Complaint fully, expeditiously and fairly. 44.3 Within two (2) Working Days of a request by the Authority, the Supplier shall provide full details of a Complaint to the Authority, including details of steps taken to achieve its resolution.

  • Problem Solving Employees and supervisors are encouraged to attempt to resolve on an informal basis, at the earliest opportunity, a problem that could lead to a grievance. If the matter is not resolved by informal discussion, or a problem-solving meeting does not occur, it may be settled in accordance with the grievance procedure. Unless mutually agreed between the Employer and the Union problem-solving discussions shall not extend the deadlines for filing a grievance. The Union Xxxxxxx or in their absence, the Local Union President, or Area Xxxxxxx, or Chief Xxxxxxx, either with the employee or alone, shall present to the appropriate supervisor a written request for a meeting. If the supervisor agrees to a problem- solving meeting, this meeting shall be held within fourteen (14) calendar days of receipt of the request. The supervisor, employee, Union Xxxxxxx, and up to one (1) other management person shall attempt to resolve the problem through direct and forthright communication. If another member of management is present that person will not be hearing the grievance at Step Two, should it progress to that Step. The employee, the Union Xxxxxxx or in their absence, the Local Union President, or Area Xxxxxxx, or Chief Xxxxxxx, may participate in problem-solving activities on paid time, in accordance with Article 31, Union Rights, Section 1H.

  • Complaint To commence a proceeding, the complaining party (or parties) shall provide by certified mail, return receipt requested, a written Complaint to the BCBSA Corporate Secretary (which shall also constitute service on BCBSA if it is a respondent) and to any Plan(s) and/or Controlled Affiliate(s) named therein. The Complaint shall contain:

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