Contractor Grievance and Appeals Policies Sample Clauses

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals shall include provisions which address the following:  The Contractor shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102, which relates to provider-enrollee communications. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal;  The Contractor shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member;  Throughout the appeals process, the Contractor shall consider the member, representative or estate representative of a deceased member as parties to the appeal;  In accordance with 42 CFR 438.406, provide the member and member representative an opportunity, before and during the appeals process, to examine the member’s case file, including medical records, and any other documents and records considered during the appeals process;  Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing;  Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative the appeal decision. The Contractor’s appeal decision notice shall describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e), which enumerates required content of a notice of resolution;  The Contractor shall notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and sickness insurer);  The Contractor shall provide members any reasonable assistance in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;  The Contractor shall ensure that the individual rendering the decision on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals with appropriate clinical expertise in treating the member’s condition or disease if the decision will be in regard to any of the following: (i) an appea...
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Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following: ▪ The Contractor must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal. ▪ The Contractor must not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member. ▪ Throughout the appeals process, the Contractor must consider the member, representative or estate representative of a deceased member as parties to the appeal per 42 CFR 438.406(b)(6). ▪ In accordance with 42 CFR 438.406(b)(5), provide the member and his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or records considered during the appeals process. ▪ Xxxxx the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing per 42 CFR 438.404(b)(4). ▪ Inform the member and member representative of the limited time available to present evidence and allegations of fact or law, in the case of expedited appeal resolution per 42 CFR 438.406(b)(4) and 42 CFR 438.408(b). ▪ Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative of the appeal decision. The Contractor’s appeal decision notice must describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e). ▪ The Contractor must acknowledge receipt of each grievance and appeal in accordance with 42 CFR 438.406(b)(1) and 42 CFR 438.228(a). ▪ The Contractor must ensure that decision makers take into account all comments documents, records, and other information submitted by the enrollee or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination per 42 CFR 438.406(b)(2)(iii) and 42 CFR 438.228(a). ▪ The Contractor must notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and s...
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Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following:  The Contractor must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal.  The Contractor must not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member.  Throughout the appeals process, the Contractor must consider the member, representative or estate representative of a deceased member as parties to the appeal.  In accordance with 42 CFR 438.406, provide the member and his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or records considered during the appeals process.  Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing.  Inform the member and member representative of the limited time available to present evidence and allegations of fact or law, in the case of expedited appeal resolution.  Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative of the appeal decision. The Contractor’s appeal decision notice must describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e).  The Contractor must acknowledge receipt of each grievance and appeal.  The Contractor must notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and sickness insurer).  The Contractor must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.  The Contractor must ensure that the individuals rendering decisions on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals with appropriate clinical ex...
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Contractor Grievance and Appeals Policies. 99 4.12.2 Inquiry Processing Requirements 101 4.12.3 Grievance Processing Requirements 101 4.12.4 Appeals Processing Requirements 102 4.12.5 External Review by Independent Review Organization 103 4.12.6 State Fair Hearing Process 104 4.12.7 Continuation of Benefits Pending Appeal & Reinstatement of Benefits 104 4.12.8 Member Notices of Action & Grievance, Appeal and Fair Hearing Procedures 105 4.12.9 Recordkeeping Requirements of Grievance and Appeals 106 4.13 Member Cost-Sharing Limits 106 5.0 Care Coordination 107 5.1 Member Assessment 107 5.1.1 Initial Screening 107 5.1.2 Comprehensive Health Assessment 109 5.1.3 Identification and Assessment of Pregnant Women 109 5.2 Stratification & Level of Service 110 5.2.1 Disease Management Level of Service 111 5.2.2 Care Management Level of Service 112 5.2.3 Complex Case Management (Member Focus) Level of Service 113 5.2.4 Complex Case Management (Provider Focus) Level of Service 114 5.2.5 Right Choices Program Level of Service 114 5.3 Care Plan Development 115 5.3.1 Disease Management Care Plans 118 5.3.2 Care Management Care Plans 118 5.3.3 Complex Case Management Care Plans 119 5.3.4 RCP Care Plans 121 5.4 Reassessments 121 6.0 Provider Network Requirements 121 6.1 Network Development 122 6.2 Network Composition Requirements 124
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Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following:
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Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following: • The Contractor must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal. • The Contractor must not take punitive action against a provider who requests or EXHIBIT 1. M SCOPE OF WORK supports an expedited appeal on behalf of a member. • Throughout the appeals process, the Contractor must consider the member, representative or estate representative of a deceased member as parties to the appeal. • In accordance with 42 CFR 438.406, provide the member and his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or records considered during the appeals process. • Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing. • Inform the member and member representative of the limited time available to present evidence and allegations of fact or law, in the case of expedited appeal resolution. • Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative of the appeal decision. The Contractor’s appeal decision notice must describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e). • The Contractor must acknowledge receipt of each grievance and appeal. • The Contractor must notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and sickness insurer).  The Contractor must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. • The Contractor must ensure that the individuals rendering decisions on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals w...
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Related to Contractor Grievance and Appeals Policies

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • Policy Grievance – Employer Grievance The Employer may institute a grievance alleging a general misinterpretation or violation by the Union or any employee by filing a written grievance with the Bargaining Unit President, with a copy to the Labour Relations Officer within twenty (20) days after the circumstances have occurred. A meeting will be held between the parties within ten (10) days. The Union shall reply within ten (10) days after the meeting, and failing settlement, the matter may be referred to arbitration. (a) 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, either of the parties may, after exhausting the grievance procedure established by this Agreement, notify the other party in writing of its decision to submit the difference or allegation to arbitration, and the notice shall contain the name of the first party's appointee to an Arbitration Board. The recipient of the notice shall, within ten (10) days, inform the other party of the name of its appointee to the Arbitration Board. The two appointees so selected shall within ten (10) days of the appointment of the second of them, appoint a third person who shall be the Chairperson. If the recipient of the notice fails to appoint a nominee, or if the two nominees fail to agree upon a Chairperson within the time limit, the appointment shall be made by the Minister of Labour for Ontario upon the request of either party. (b) Within thirty (30) calendar days of the receipt of notice referred to in Article 8.12(a) above, either party may require a process for a sole arbitrator where the grievance concerns: i) a job posting ii) a short term layoff

  • Policy Grievances ‌ Where either party to this agreement disputes the general application, interpretation or alleged violation of an article of this agreement, the dispute shall be discussed initially with the Executive Director or designate or the President of the Union within 14 calendar days of the occurrence. Where no satisfactory agreement is reached, either party, within a further 14 calendar days, may submit the dispute to arbitration.

  • Policy Grievance Where either Party disputes the general application, interpretation or alleged violation of an article of this Agreement, the dispute shall be discussed initially with the Employer or the Union, as the case may be, within thirty (30) days of the occurrence. Where no satisfactory agreement is reached, either Party may submit the dispute to arbitration, as set out in Article 10.

  • Grievance Commissioner System This is to confirm the discussion of the parties during collective bargaining that they are committed to encouraging early discussion and resolution of labour relations issues at the local level and seek to resolve grievances in a timely and cost efficient manner. To that end, this is to confirm that pursuant to Article 8, the parties agree that the Employer and Union at individual nursing homes may agree to utilize the following process in order to resolve a particular grievance through the utilization of a joint mediation-arbitration procedure:

  • Policy Grievance – Union Grievance The Union may institute a grievance alleging a general misinterpretation or violation of this Agreement by the Employer by submitting a written grievance at Step No. 1 within twenty (20) days after the circumstances have occurred. This section shall not apply to disciplinary grievances or application of competitive clauses under this Agreement.

  • Grievances and Appeals a. If you have questions about any pediatric dental services received, please first discuss the matter with your Dental Provider. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center. You can also email questions by accessing the “Contact Us” section of the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.

  • 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.

  • Selection of Subcontractors, Procurement of Materials and Leasing of Equipment The contractor shall not discriminate on the grounds of race, color, religion, sex, national origin, age or disability in the selection and retention of subcontractors, including procurement of materials and leases of equipment. The contractor shall take all necessary and reasonable steps to ensure nondiscrimination in the administration of this contract. a. The contractor shall notify all potential subcontractors and suppliers and lessors of their EEO obligations under this contract. b. The contractor will use good faith efforts to ensure subcontractor compliance with their EEO obligations.

  • Complaints and Appeals As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

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