Continuation of Benefits Pending Appeal & Reinstatement of Benefits Sample Clauses

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:  The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  The services were ordered by an authorized provider;  The original period covered by the original authorization has not expired; and  The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:  The member withdraws the request;  Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  The time period or service limits of a previously authorized services has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall pay for those services.
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Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:  The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  The services were ordered by an authorized provider;  The original period covered by the original authorization has not expired; and  The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:  The member withdraws the request;  Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten
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Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420(a), 42 CFR 438.420(b)(1) - (5), and 42 CFR 438.402(c)(2)(ii). The Contractor must continue the member’s benefits if: • The member or provider files the request for an appeal within sixty (60) days following the date on the adverse benefit determination notice. • The member or provider files the request for continuation of benefits within ten (10) days of the Contractor mailing the notice or the intended effective date of the proposed adverse benefit determination, whichever is later; • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
Sample 1

Related to Continuation of Benefits Pending Appeal & Reinstatement of Benefits

  • Continuation of Benefits (i) For a period of three years following the Termination of Employment (the “Benefit Continuation Period”), the Employee shall be treated as if Employee had continued to be an executive for all purposes under the Company’s health insurance plan and dental insurance plan; or if the Employee is prohibited from participating in such plans, the Company shall otherwise provide such benefits. Employee shall be responsible for any employee contributions for such insurance coverage. Following the Benefit Continuation Period, Employee shall be entitled to receive continuation coverage under Part 6 of Title I of ERISA (“COBRA Benefits”) by treating the end of this period as the applicable qualifying event (i.e., as a termination of employment) for purposes of ERISA Section 603(2)) and with the concurrent loss of coverage occurring on the same date, to the extent allowed by applicable law. (ii) For the Benefit Continuation Period, the Company shall maintain in force, at its expense, the Employee’s life insurance in effect under the Company’s voluntary life insurance benefit plan as of the Change-in-Control Date or as of the date of Termination of Employment, whichever coverage limits are greater. For purposes of clarification, the portion of the premiums in respect of such voluntary life insurance for which Employee and the Company are responsible, respectively, shall be the same as the portion for which the Company and Employee are responsible, respectively, immediately prior to the date of Termination of Employment or the Change-in-Control Date, as applicable. (iii) For the Benefit Continuation Period, the Company shall provide short-term and long-term disability insurance benefits to Employee equivalent to the coverage that the Employee would have had Employee remained employed under the disability insurance plans applicable to Employee on the date of Termination of Employment, or, at the Employee’s election, the plans applicable to Employee as of the Change-in-Control Date. Should Employee become disabled during such period, Employee shall be entitled to receive such benefits, and for such duration, as the applicable plan provides. For purposes of clarification, the portion of the premiums in respect of such short-term and long-term disability benefits for which Employee and the Company are responsible, respectively, shall be the same as the portion for which Employee and the Company are responsible, respectively, immediately prior to the date of Termination of Employment or the Change-in-Control Date, as applicable. (iv) Notwithstanding anything in this Agreement to the contrary, in no event shall the provision of in-kind benefits pursuant to this Section 3 during any taxable year of Employee affect the provision of in-kind benefits pursuant to this Section 3 in any other taxable year of Employee.

  • Termination of Benefits Except as provided in Section 2 above or as may be required by law, Executive’s participation in all employee benefit (pension and welfare) and compensation plans of the Company shall cease as of the Termination Date. Nothing contained herein shall limit or otherwise impair Executive’s right to receive pension or similar benefit payments that are vested as of the Termination Date under any applicable tax-qualified pension or other plans, pursuant to the terms of the applicable plan.

  • Extension of Benefits Upon termination of insurance, whether due to termination of eligibility, or termination of the Contract, an extension of benefits shall be provided for a period of no less than 30 days for completion of a dental procedure that was started before Your coverage ended.

  • Duration of Benefits Eligibility for Income Protection benefits will cease upon the earliest of the following dates: 1.09.01 the date the member is no longer disabled from performing the duties of their regular position, or any alternative employment made available to the member by the City. 1.09.02 the date the member's Income Protection benefits have been expended. 1.09.03 the date the member dies.

  • Denial of Benefits Subject to prior notification and consultation, a Party may deny the benefits of this Chapter to: (a) investors of the other Party where the investment is being made by a enterprise that is owned or controlled by persons of a third State and the enterprise has no substantive business activities in the territory of the other Party; or (b) investors of the other Party where the investment is being made by a enterprise that is owned or controlled by persons of the denying Party.

  • Cessation of Benefits An employee shall cease to be eligible for benefits of this Plan at the earliest of the following dates: (a) at the end of the month in which the employee reaches his/her sixty-fifth (65th) birthday; (b) on the date of commencement of paid absence prior to retirement; (c) on the date of termination of employment with the Employer. Benefits will not be paid when an employee is serving a prison sentence. Cessation of active employment as a regular employee shall be considered termination of employment except when an employee is on authorized leave of absence with or without pay.

  • Retention of Benefits Union leave under the following four (4) sections will be unpaid. The Employer will maintain regular pay and xxxx the Union for the costs of the employee’s salary and benefits. If the Union member is part-time or casual, and the leave is greater than their normal work hours, the Employer will pay the employee for the full length of the leave requested by the Union. The Employer will xxxx the Union for these days as noted above. The Union will pay these invoices within twenty-eight (28) days. Union leave is not unpaid leave for the purposes of Article 22.02 [i.e. such leave will not affect the employee’s benefits, seniority or increment anniversary date].

  • Payment of Benefits All or part of the contract benefits may be paid under one or more of the following: - a variable payment plan; - a fixed payment plan; or - in cash. The provisions and rate for variable and fixed payment plans are described in Section 11. Contract benefits may not be placed under a payment plan unless the plan would provide to each beneficiary a monthly income the initial amount of which is at least the minimum payment amount shown on page 4. A Withdrawal Charge will be deducted from contract benefits before their payment under certain conditions described in Section 7.3.

  • Commencement of Benefits The benefits commence six (6) months from the date that disability began, which shall include the period of payment under the terms of the Short Term Income Protection Plan. Proof of disability must be submitted within six (6) months following the Qualifying Period.

  • Limitation of Benefits (a) Anything in this Agreement to the contrary notwithstanding, in the event it shall be determined that any benefit, payment or distribution by the Company or any of its direct and/or indirect subsidiaries to or for the benefit of Employee (whether paid or payable or distributed or distributable pursuant to the terms of this Agreement or otherwise, but determined without regard to any additional payments required under this Section 18) (such benefits, payments or distributions are hereinafter referred to as “Payments”) would, if paid, be subject to the excise tax imposed by Section 4999 of the Code (the “Excise Tax”), then, prior to the making of any Payments to Employee, a calculation shall be made comparing (i) the net after-tax benefit to Employee of the Payments after payment by Employee of the Excise Tax, to (ii) the net after-tax benefit to Employee if the Payments had been limited to the extent necessary to avoid being subject to the Excise Tax. If the amount calculated under (i) above is less than the amount calculated under (ii) above, then the Payments shall be limited to the extent necessary to avoid being subject to the Excise Tax (the “Reduced Amount”). The reduction of the Payments due hereunder, if applicable, shall be made by first reducing cash Payments and then, to the extent necessary, reducing those Payments having the next highest ratio of Parachute Value to actual present value of such Payments as of the date of the change of control, as determined by the Determination Firm (as defined in Section 18(b) below). For purposes of this Section 18, present value shall be determined in accordance with Section 280G(d)(4) of the Code. For purposes of this Section 18, the “Parachute Value” of a Payment means the present value as of the date of the change of control of the portion of such Payment that constitutes a “parachute payment” under Section 280G(b)(2) of the Code, as determined by the Determination Firm for purposes of determining whether and to what extent the Excise Tax will apply to such Payment. (b) All determinations required to be made under this Section 18, including whether an Excise Tax would otherwise be imposed, whether the Payments shall be reduced, the amount of the Reduced Amount, and the assumptions to be used in arriving at such determinations, shall be made by an independent, nationally recognized accounting firm or compensation consulting firm mutually acceptable to the Company and Employee (the “Determination Firm”) which shall provide detailed supporting calculations both to the Company and Employee. All fees and expenses of the Determination Firm shall be borne solely by the Company. Any determination by the Determination Firm shall be binding upon the Company and Employee. As a result of the uncertainty in the application of Section 4999 of the Code at the time of the initial determination by the Determination Firm hereunder, it is possible that Payments hereunder will have been unnecessarily limited by this Section 18 (“Underpayment”), consistent with the calculations required to be made hereunder. The Determination Firm shall determine the amount of the Underpayment that has occurred and any such Underpayment shall be promptly paid by the Company to or for the benefit of Employee, but no later than March 15 of the year after the year in which the Underpayment is determined to exist, which is when the legally binding right to such Underpayment arises.

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