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.
Reasonable Suspicion Testing All Employees Performing Safety-Sensitive Functions
A. Reasonable suspicion testing for alcohol or controlled substances may be directed by the Employer for any employee performing safety-sensitive functions when there is reason to suspect that alcohol or controlled substance use may be adversely affecting the employee’s job performance or that the employee may present a danger to the physical safety of the employee or another.
B. Specific objective grounds must be stated in writing that support the reasonable suspicion. Examples of specific objective grounds include but are not limited to:
1. Physical symptoms consistent with alcohol and/or controlled substance use;
2. Evidence or observation of alcohol or controlled substance use, possession, sale, or delivery; or
3. The occurrence of an accident(s) where a trained manager, supervisor or lead worker suspects alcohol or other controlled substance use may have been a factor.
PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:
Independence from Material Breach Determination Except as set forth in Section X.D.1.c, these provisions for payment of Stipulated Penalties shall not affect or otherwise set a standard for OIG’s decision that Xxxxx has materially breached this IA, which decision shall be made at OIG’s discretion and shall be governed by the provisions in Section X.D, below.
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.
Reasonable Suspicion a. Reasonable suspicion to test a Covered Employees for illegal drugs or alcohol will exist when specific, reliable objective facts and circumstances would create a good faith belief in a prudent person that the employee has used a drug or alcohol. Such circumstances include, but are not limited to, the employee’s behavior or appearance while on any SFMTA jobsite, while on SFMTA business or in SFMTA facilities, and recognized and accepted symptoms of intoxication or impairment caused by drugs or alcohol, that are not reasonably explained by other causes such as fatigue, lack of sleep, proper use of prescription drugs, or reaction to noxious fumes or smoke.
b. Any individual or employee can report an employee who may be under the influence of alcohol or drugs. Upon receiving a report of possible alcohol or illegal drugs on the job, two (2) trained employer representatives will verify and document the basis for the suspicion and request testing. The first employer representative shall verify and document the employee’s appearance and behavior based on the above-stated indicators and, if appropriate, recommend testing to the second employer representative. At work locations within the border of the City and County of San Francisco (including San Francisco International Airport), the second employer representative shall verify and document the appearance and behavior of the employee based on the above-stated indicators and has final authority to require the employee to be tested. At work locations outside the border of the City and County of San Francisco, the second employer representative shall confer with the first employer representative to verify the employee’s behavior based on the above-stated indicators, and the second employer representative has the final authority to require the employee to be tested. In the event only one trained employer representative is available onsite, the representative shall confer with any other trained employer representative within the City to verify the employee’s behavior. The second trained employer representative shall have the final authority to require the employee to be tested.
c. If the SFMTA requires an employee to be tested under reasonable suspicion, then the employee may ask for representation. Representation may include, but is not limited to, union representatives and shop stewards. If the employee requests representation, the SFMTA may allow a reasonable amount (a maximum of one hour) of time for the employee to obtain representation. Such request shall not delay the administration of the tests for more than one hour from the time the employee is notified that the employee will be tested.
d. Moreover, if the SFMTA has reasonable suspicion or suspect that a prescription medication may have interfered with or may have had a direct impact on an employee’s job performance, it may require that employee to be tested.
e. The department representative(s) shall be required to accurately document and file the incident and the employee shall be required to complete a consent form prior to any testing. If an employee refuses to Submit to testing, then the SFMTA shall treat the refusal as having tested positive and shall immediately take appropriate disciplinary action pursuant to the attached discipline matrix.
f. The SFMTA shall bear the costs for any required testing for alcohol and/or drugs under this section. Any counseling and rehabilitation services shall be on the employee’s time and at the employee’s cost, except that employees may use accrued paid time off to attend treatment and may utilize any resources covered by insurance. Employees shall have the right to use any accrued but unused leave balances while enrolled in any counseling or rehabilitation program. Any request by an employee to re-test a specimen shall be at the employee’s cost.
Notice of Criminal Activity and Disciplinary Actions a. Xxxxxxx shall immediately report in writing to their contract manager when Xxxxxxx has knowledge or any reason to believe that they or any person with ownership or controlling interest in the organization/business, or their agent, employee, contractor or volunteer that is providing services under this Contract has:
1. Engaged in any activity that could constitute a criminal offense equal to or greater than a Class A misdemeanor or grounds for disciplinary action by a state or federal regulatory authority; or
2. Been placed on community supervision, received deferred adjudication, or been indicted for or convicted of a criminal offense relating to involvement in any financial matter, federal or state program or felony sex crime.
b. Grantee shall not permit any person who engaged, or was alleged to have engaged, in any activity subject to reporting under this section to perform direct client services or have direct contact with clients, unless otherwise directed in writing by the System Agency.
Root Cause Analysis Upon Vendor's failure to provide the Services in accordance with the applicable Service Levels (for any reason other than a Force Majeure Event) Vendor will promptly (a) perform a root-cause analysis to identify the cause of such failure, (b) provide Prudential with a report detailing the cause of, and procedure for correcting, such failure, (c) obtain Prudential's written approval of the proposed procedure for correcting such failure, (d) correct such failure in accordance with the approved procedure, (e) provide weekly (or more frequent, if appropriate) reports on the status of the correction efforts, and (f) provide Prudential with assurances satisfactory to Prudential that such failure has been corrected and will not recur.
Right to Grieve Disciplinary Action Employees shall have the right to grieve written censures or warnings, and adverse employee appraisals. Employees shall have the right to rebut in writing any disciplinary notice and that rebuttal will be placed in the employee file, but will not be part of the formal disciplinary record. Should an employee dispute any such entry in his/her file, he/she shall be entitled to recourse through the Grievance Procedure and the eventual resolution thereof shall become part of his/her personal record.
Tardiness Tardiness shall be defined as reporting to work eight (8) or more minutes after clock in time. For each three (3) occurrences of tardiness in a school year shall constitute grounds for the issuance of progressive discipline as defined in Article 15.
