Direct audits Sample Clauses

Direct audits. In addition to the audit of the audits undertaken by the Insurer referred in Clause 23.3.1.a, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected or partially settled by the Insurer to assure itself of the legitimacy of the Insurer’s decisions. Claims settlement decisions of the Insurer that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive):  Evidence of rigorous review of claims adjudication.  Comprehensiveness of claims submissions (documentation) by the EHCPs.  Number of type of queries raised by the Insurer during review of claims – appropriateness of queries.  Accuracy of claims settlement.
Sample 1Sample 2See All (6)
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Direct audits. In addition to the audit of the audits undertaken by the ISA referred in Clause 23.3.1.a, the NHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include:
Sample 1
Direct audits. In addition to the audit of the audits undertaken by the ISA referred in Schedule 12, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive): • Evidence of rigorous review of claims adjudication. • Comprehensiveness of claims submissions (documentation) by the EHCPs. • Number of type of queries raised by the ISA during review of claims – appropriateness of queries. • Accuracy of claims settlement.
Sample 1

Related to Direct audits

  • Contract Audits Eligible Purchaser represents and warrants that it shall cooperate with Enterprise Services, the Office of the State Auditor, federal officials, and/or any third party authorized by law or contract, in any audit conducted by such party pertaining to any Contracts that Eligible Purchaser has made purchases from pursuant to this Agreement, including providing records related to any purchases from such Contracts.

  • Audits No more than once a year, or following unauthorized access, upon receipt of a written request from the LEA with at least ten (10) business days’ notice and upon the execution of an appropriate confidentiality agreement, the Provider will allow the LEA to audit the security and privacy measures that are in place to ensure protection of Student Data or any portion thereof as it pertains to the delivery of services to the LEA . The Provider will cooperate reasonably with the LEA and any local, state, or federal agency with oversight authority or jurisdiction in connection with any audit or investigation of the Provider and/or delivery of Services to students and/or LEA, and shall provide reasonable access to the Provider’s facilities, staff, agents and XXX’s Student Data and all records pertaining to the Provider, LEA and delivery of Services to the LEA. Failure to reasonably cooperate shall be deemed a material breach of the DPA.

  • City Audits The CITY may perform an independent audit. Such audits may cover programmatic as well as fiscal matters. GRANTEE will be afforded an opportunity to respond to any audit findings, and have the responses included in the final audit report. Costs of such audits will be borne by the CITY.

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