Complaints, Grievances and Appeals. Leave of absence with pay may be granted by the Employing Authority to officers and members of the Union in the following circumstances:
(a) if a Xxxxxxx is required to investigate an urgent complaint of fellow employees,
(b) to make a complaint on their own behalf,
(c) to be involved in the consultation process, or
(d) if an employee is processing a grievance or is attending at a hearing of their grievance before an Adjudication Board or the hearing of their classification appeal.
Complaints, Grievances and Appeals. Information on how Provider or Provider’s authorized representative can submit complaints and file grievances and appeals, and the resolution process, is contained in the applicable provider manual.
Complaints, Grievances and Appeals. This Se tion explains how to file a Complaint, Grievance and Appeal. Overview 1 a
Complaints, Grievances and Appeals. Leave of absence with pay shall be granted by the Employer to officers and members of the Union in the following circumstances:
(a) if a Xxxxxxx is required to investigate an urgent complaint of fellow employees,
(b) to make a complaint on his/her own behalf,
(c) to be involved in the consultation process, including serving as a member of any Joint Committees established by the parties, or
(d) if an employee is processing a grievance, or is attending at a hearing of his/her grievance before an Arbitration Board or the hearing of his/her classification appeal.
Complaints, Grievances and Appeals. 4.9.1 To the extent not covered below, the PASSE’s grievance and appeal system must comply with the requirements set forth in §160.000 and §190.000 of the Medicaid Provider Manual, and with all applicable federal and state laws, rules, and regulations, including 42 CFR Part 431, Subpart E (Fair Hearings for Applicants and Beneficiaries) and 42 CFR Part 438, Subpart F (Grievance and Appeal System), the Medicaid Fairness Act, and the Arkansas Administrative Procedures Act (Ark. Code Xxx. § 00-00-000 et seq.).
4.9.2 The PASSE must ensure that all adverse decisions/adverse actions, grievance or complaint decisions, and appeal resolutions are made by qualified personnel. The decision maker must be a qualified health care professional with the appropriate clinical expertise in treating the member’s condition or disease, if:
a. If the decision involves an appeal of a denial based on lack of medical necessity;
b. If the decision involves a grievance regarding denial of expedited resolution of an appeal; or
c. If the decision involves a grievance or appeal involving clinical issues.
4.9.3 The PASSE must ensure that the decision makers on adverse decisions/adverse actions, complaints, grievances, and appeals are not:
a. Involved in any previous level of review or decision-making; and
b. The subordinate of any individual who was involved in a previous level of review or decision-making.
4.9.4 If approved by DHS, the PASSE may elect to have all appeals and grievances resolved by an independent review organization through an external review process. The independent review organization is subject to all applicable provisions of the Agreement.
4.9.5 The PASSE shall not take any punitive action against an enrolled member or a provider for filing or participating in a compliant, grievance or appeal.
Complaints, Grievances and Appeals. Information on how Provider or Provider’s authorized representative shall submit complaints and file grievances and appeals, and the resolution process, is contained in the Subcontractor or CCO MississippiCHIP Provider Manual.
Complaints, Grievances and Appeals. 90 Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 Premium Payment 131 General Provisions 132 Glossary of Terms 137 Exhibit A – Vision 156 Exhibit B – Healthways Gym Membership 158 WELCOME TO PRESBYTERIAN HEALTH PLAN! Our Agreement With You Understanding This Agreement Refer To – This “Refer To” symbol will direct you to read related information in Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when Timeframe associated with this item Important
Complaints, Grievances and Appeals. 90 Records 113 Eligibility, Enrollment, Effective Dates, Termination and Continuation 120 Premium Payment 130 General Provisions 131 Glossary of Terms 136 Exhibit A – Vision 154 Exhibit B – Healthways Gym Membership 156 Our Agreement With You
Complaints, Grievances and Appeals. This Se xxxx explains how to file a Complaint, Grievance and Appeal. Overview CSC Call P 505‐923‐6980 1‐800‐923‐6980 t a t Computation of Time
Complaints, Grievances and Appeals. The Provider shall develop, implement and maintain a system for tracking and resolving Beneficiary complaints and appeals regarding its services, processes, procedures, and staff. The Provider shall respond fully and completely to each complaint and establish a tracking mechanism to document the status and finally disposition of each appeal. Beneficiary complaints and appeals shall be subject to disposition consis tent with applicable insurance law or regulations. The Provider shall resolve at a minimum ninety-eight percent (98%) of Beneficiary complaints and appeals shall be resolved within thirty calendar (30) days.
