Expedited Internal Appeal Process Sample Clauses

Expedited Internal Appeal Process. The Enrollee or their authorized representative has the right to request, orally or in writing, and receive an expedited Appeal decision affecting the Enrollee’s treatment in a time-sensitive situation. The Enrollee must ask for an expedited 72-hour review when the Appeal request is made. The Enrollee need not use the words “expedited” when making the request for an urgent or fast action. The Contractor must inform the Enrollee of the limited time available for the Enrollee to present evidence and allegations of fact or law, in person and in writing, in the case of expedited resolution. The Contractor must ensure that punitive action is not taken against a provider who either requests an expedited resolution or supports an Enrollee’s Appeal. If the Contractor decides, based on medical criteria, that the Enrollee’s situation is time-sensitive, or if any physician or other provider of an Enrollee’s services makes the request for the Enrollee or calls or writes in support of the request for an expedited review, the Contractor must issue a decision as expeditiously as the Enrollee’s health requires, but no later than 72 hours after receiving the request. The Contractor may extend this time frame by up to 14 calendar days if the Enrollee requests the extension or if the Contractor justifies the need for additional information and how the extension of time benefits the Enrollee. For any extension not requested by the Enrollee, the Contractor must give the Enrollee written notice of the reason for the delay. The Contractor must make a decision as expeditiously as the Enrollee’s health requires, but no later than the end of any extension period.
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Expedited Internal Appeal Process. 1) The Enrollee has the right to request and receive an expedited Appeal decision affecting the Enrollee’s medical treatment in a time-sensitive situation. The Enrollee must ask for an expedited 72-hour review when the Appeal request is made.
Sample 1

Related to Expedited Internal Appeal Process

  • External Appeals For appeals of a decision that a prescription drug is not covered because it is not on our formulary, please see the Formulary Exception Process in the Prescription Drug and Diabetic Equipment and Supplies section. When filing a reconsideration or an appeal, please provide the same information listed in the Complaints section above.

  • External Arbitration Procedures Any arbitration initiated under this LGIA shall be conducted before a single neutral arbitrator appointed by the Parties. If the Parties fail to agree upon a single arbitrator within ten (10) Calendar Days of the submission of the dispute to arbitration, each Party shall choose one arbitrator who shall sit on a three-member arbitration panel. The two arbitrators so chosen shall within twenty (20) Calendar Days select a third arbitrator to chair the arbitration panel. In either case, the arbitrators shall be knowledgeable in electric utility matters, including electric transmission and bulk power issues, and shall not have any current or past substantial business or financial relationships with any party to the arbitration (except prior arbitration). The arbitrator(s) shall provide each of the Parties an opportunity to be heard and, except as otherwise provided herein, shall conduct the arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association (“Arbitration Rules”) and any applicable FERC regulations; provided, however, in the event of a conflict between the Arbitration Rules and the terms of this Article 27, the terms of this Article 27 shall prevail.

  • How to Request an External Appeal If you remain dissatisfied with our medical appeal determination, you may request an external review by an outside review agency. In accordance with §27-18.9-8, your external appeal will be reviewed by one of the external independent review organizations (IRO) approved by the Office of the Health Insurance Commissioner. The IRO is selected using a rotational method. Your claim does not have to meet a minimum dollar threshold in order for you to be able to request an external appeal. To request an external appeal, submit a written request to us within four (4) months of your receipt of the medical appeal denial letter. We will forward your request to the outside review agency within five (5) business days, unless it is an urgent appeal, and then we will send it within two (2) business days. We may charge you a filing fee up to $25.00 per external appeal, not to exceed $75.00 per plan year. We will refund you if the denial is reversed and will waive the fee if it imposes an undue hardship for you. Upon receipt of the information, the outside review agency will notify you of its determination within ten (10) calendar days, unless it is an urgent appeal, and then you will be notified within seventy-two (72) hours. The determination by the outside review agency is binding on us. Filing an external appeal is voluntary. You may choose to participate in this level of appeal or you may file suit in an appropriate court of law (see Legal Action, below). Once a member or provider receives a decision at one of the several levels of appeals noted above, (reconsideration, appeal, external), the member or provider may not ask for an appeal at the same level again, unless additional information that could affect such decisions can be provided.

  • Complaints Procedure 18.1 If the Client has any cause for complaint in relation to the services provided by the Company, he should file a complaint as per the Company’s Complaint Handling policy which is available on the Company’s website.

  • COMPLAINT AND GRIEVANCE PROCEDURE 12.01 Matters pertaining to the interpretation or application of this Agreement, together with complaints and grievances, shall be discussed and adjusted by the Board's designated representatives and the Union Committee.

  • Complaints by Bidders and Handling of Complaints (ix) The Recipient shall implement an effective and independent protest mechanism allowing bidders to protest and to have their protests handled in a timely manner. Fraud and Corruption

  • Appeal Process PROVIDER may appeal any adverse finding by the Contract Compliance Officer as set forth in sec. 25.08(20)(c), D.C. Ords.

  • COMPLAINT PROCEDURES CONTRACTOR shall maintain and adhere to its written procedures for responding to parent complaints. These procedures shall include annually notifying and providing parents of LEA students with appropriate information (including complaint forms) for the following: (1) Uniform Complaint Procedures pursuant to Title 5 of the California Code of Regulations section 4600 et seq.; (2) Nondiscrimination policy pursuant to Title 5 of the California Code of Regulations section 4960 (a); (3) Sexual Harassment Policy, California Education Code 231.5 (a) (b) (c); (4) Title IX Pupil Grievance Procedure, Title IX 106.8 (a) (d) and 106.9 (a); and (5) Notice of Privacy Practices in compliance with Health Insurance Portability and Accountability Act (HIPAA), if applicable. CONTRACTOR shall include verification of these procedures to the LEA upon request. CONTRACTOR shall immediately notify LEA of any complaints filed against it related to LEA students and provide LEA with all documentation related to the complaints and/or its investigation of complaints, including any and all reports generated as a result of an investigation.

  • Classification Appeal Procedure An employee shall have the right to appeal, through the Union, the classification of the position the employee occupies, or where a point rating plan has been used, the right to appeal the position's level. Classification matters are not grievable under Article 8 of this Agreement. Instead, the following procedures shall be followed.

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