Expedited Medical Necessity Appeal Sample Clauses

Expedited Medical Necessity Appeal. An Expedited Appeal process is available to review a Medical Necessity Appeal involving an urgent care claim. An urgent care claim is a claim where the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant to regain maximum function, or, in the opinion of a Provider with knowledge of the claimant’s condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is subject to the claim. An Expedited Appeal shall be made available to, and may be initiated by the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf. Requests for an Expedited Appeal may be verbal or written. For verbal Expedited Appeals, call 0-000-000-0000 or 0-000-000-0000. For written Expedited Appeals, mail to: P. O. Box 791 Latham, NY 12110 Xxxxx Vision will make a decision no later than seventy-two (72) hours of receipt of an Expedited Appeal. You may contact the Commissioner of Insurance directly for assistance with any Appeal issues at the following address and phone numbers: Commissioner of Insurance P. O. Box 94214 To the extent this is an ERISA plan, the Member is entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). For purposes of this provision, the Group is considered the Plan Administrator and will be subject to the provisions stated below. ERISA provides that all Plan Participants (Members) shall be entitled to: A Member may examine, without charge, at the plan administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the United States Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Upon written request to the plan administrator, a Member may obtain copies of documents governing the operation of the plan, including any applicable insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The plan administrator may make a reasonable charge for the copies. A Member may receive a summary of the plan’s annual financial report. The Plan Administrator is required by law to furnis...
Sample 1
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Expedited Medical Necessity Appeal. An Expedited Appeal process is available to review a Medical Necessity Appeal involving an urgent care claim. An urgent care claim is a claim where the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant to regain maximum function, or, in the opinion of a Provider with knowledge of the claimant’s condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is subject to the claim. An Expedited Appeal shall be made available to, and may be initiated by the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf. Requests for an Expedited Appeal may be verbal or written. For verbal Expedited Appeals, call 0-000-000-0000 or 0-000-000-0000. For written Expedited Appeals, mail to:
Sample 1
Expedited Medical Necessity Appeal. An Expedited Appeal process is available to review a Medical Necessity Appeal involving an urgent care claim. An urgent care claim is a claim where the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant to regain maximum function, or, in the opinion of a Provider with knowledge of the claimant’s condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is subject to the claim. An Expedited Appeal shall be made available to, and may be initiated by the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf. Requests for an Expedited Appeal may be verbal or written. For verbal Expedited Appeals, call 0-000-000-0000 or 0-000-000-0000. Quality Assurance Department P. O. Box 791 Latham, NY 12110 Xxxxx Vision will make a decision no later than seventy -two (72) hours of receipt of an Expedited Appeal. You may contact the Commissioner of Insurance directly for assistance with any Appeal issues at the following address and phone numbers: Commissioner of Insurance P. O. Box 94214 Baton Rouge, LA 70804-9214 0-000-000-0000 or 0-000-000-0000
Sample 1
Expedited Medical Necessity Appeal. An Expedited Appeal process is available to review a Medical Necessity Appeal involving an urgent care claim. An urgent care claim is a claim where the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant to regain maximum function, or, in the opinion of a Provider with knowledge of the claimant’s condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is subject to the claim. Commissioner of Insurance P. O. Box 94214 Baton Rouge, LA 70804-9214 0-000-000-0000 or 0-000-000-0000
Sample 1

Related to Expedited Medical Necessity Appeal

  • Office of Inspector General Investigative Findings Expert Review In accordance with Senate Bill 799, Acts 2021, 87th Leg., R.S., if Texas Government Code, Section 531.102(m-1)(2) is applicable to this Contract, Contractor affirms that it possesses the necessary occupational licenses and experience.

  • PROFESSIONAL RESPONSIBILITY (APPLIES TO RNS ONLY 19.01 The parties agree that resident care is enhanced if concerns relating to professional practice and workload are resolved in a timely and effective manner, as set out below; In the event that the Home assigns a number of residents or a workload to an individual employee or group of employees, such that she or they have cause to believe that she or they are being asked to perform more work than is consistent with proper resident care, she or they shall: i) At the time the workload issue occurs, discuss the issue within the Home to develop strategies to meet resident care needs using current resources. If necessary, using established lines of communication, seek immediate assistance from an individual(s) identified by the Home who has responsibility for timely resolution of workload issues. ii) Failing resolution at the time of occurrence of the workload issue, complain in writing to the Union-Management Committee within twenty (20) calendar days of the alleged improper assignment. The chairperson of the Union-Management Committee shall convene a meeting of the Union-Management Committee within twenty (20) calendar days of the filing of the complaint. The Union-Management Committee shall hear and attempt to resolve the complaint to the satisfaction of both parties. The Employer will provide a written response to the Union, with a copy to the ONA representation within ten (10) calendar days. iii) Prior to the complaint being forwarded to the Independent Assessment Committee, the Union may forward a written report outlining the complaint and recommendations to the Director of Resident Care and/or the Administrator. iv) At any time during this process, the parties may agree to the use of a mediator to assist in the resolution of the Professional Practice issues. v) Any settlement arrived at under 19.01 (a) i) – iii) shall be signed by the parties. vi) Failing resolution of the complaint within twenty (20) calendar days of the meeting of the Union-Management Committee, the complaint shall be forwarded to an independent Assessment Committee composed of three (3) registered nurses; one chosen by the Ontario Nurses' Association, one chosen by the Home and one chosen from a panel of independent registered nurses who are well respected within the profession. The member of the Committee chosen from the panel of independent registered nurses shall act as Chairperson. vii) The Independent Assessment Committee shall set a date to conduct a hearing into the complaint, within twenty (20) calendar days of its appointment, and shall be empowered to investigate as is necessary to properly assess the merits of the complaint. The Independent Assessment Committee shall report its findings, in writing, to the parties within twenty (20) calendar days following completion of its hearing. (b) i) The list of Independent Assessment Committee Chairpersons is attached as Appendix “B”. The members of the panel shall sit in rotation as agreed by the parties. If a panel member is unable to sit within the time limit stipulated, the panel member next scheduled to sit will be appointed by the parties.

  • Arbitration Appeal A. If an employee grievance is not resolved at Step 2, the aggrieved employee or the PBA may, within fifteen (15) calendar days after receipt of the Step 2 response, submit a request for arbitration to the Labor Relations Office. B. In non-disciplinary grievances, either the PBA or the Employer may request to take the issue or grievance directly to arbitration by submitting the request for arbitration to the Labor Relations Office. C. If the parties fail to mutually agree upon an arbitrator within five (5) calendar days after the date of receipt of the arbitration request, a list of seven (7) qualified neutrals shall be requested and paid for by the moving party from the Federal Mediation and Conciliation Service (FMCS). Within fifteen (15) calendar days after receipt of the list, the parties shall meet and alternately strike names on the list, and the remaining name shall be the arbitrator. A coin shall be tossed to determine who shall strike first. Each party has the right to reject one list. The party rejecting the list shall be responsible for paying for and obtaining the next list and the above described procedures will be followed for selection from the list. If the selected arbitrator is not available for a hearing within ninety (90) days of the date the arbitrator was selected, another list may be requested by the Labor Relations Office, which will pay the fee for that particular list. If the grievant is not represented by the Union, the list of arbitrators shall be requested from the American Arbitration Association with the moving party paying whatever fees may be charged. Once a list has been obtained, the procedures detailed above shall be used for selecting an arbitrator. D. The hearing on the grievance shall be informal and the rules of evidence shall not apply; however, to assure an orderly hearing, the rules of judicial procedure should be followed as closely as possible.

  • GRIEVANCE ARBITRATION Notwithstanding any other provision of this Agreement, for the purposes of this Article, an Employee has the right to grieve any filling of a vacancy or Assignment in the bargaining unit.

  • Recognition of Union Stewards and Grievance Committee In order to provide an orderly and speedy procedure for the settling of grievances, the Employer acknowledges the rights and duties of the Union Stewards. The Xxxxxxx shall assist any Employee, which the Xxxxxxx represents, in preparing and presenting her grievance in accordance with the grievance procedure.

  • Joint Occupational Health and Safety Committee The Employer and the Union recognize the role of the joint Occupational Health and Safety Committee in promoting a safe and healthful workplace. The parties agree that a Joint Occupational Health and Safety Committee shall be established for each Employer covered by this Collective Agreement. The Committee shall govern itself in accordance with the provisions of the Industrial Health and Safety Regulations made pursuant to the Workers’ Compensation Act. The Committee shall be as between the Employer and the Union, with equal representation, and with each party appointing its own representatives. Representatives of the Union shall be chosen by the Union membership or appointed by the Union. All minutes of the meetings of the Joint Occupational Health & Safety Committee will be recorded in a mutually agreeable format and will be sent to the Union. The Union further agrees to actively pursue with the other Health Care Unions a Joint Union Committee for the purposes of this Article. The Employer agrees to provide or cause to be provided to Employer members of the Joint Occupational Health and Safety Committee adequate training and orientation to the duties and responsibilities of committee members to allow the incumbents to fulfil those duties competently. The Union agrees to provide or cause to be provided to Union members of the Joint Occupational Health and Safety Committee adequate training and orientation to the duties and responsibilities of committee members to allow the incumbents to fulfil those duties competently. Such training and orientation shall take place within six (6) months of taking office.

  • GRIEVANCE ARBITRATION PROCEDURE 8.01 For purposes of this Agreement, a grievance is defined as a difference arising between the parties relating to the interpretation, application, administration or alleged violation of the Agreement, including any question as to whether a matter is arbitrable. 8.02 In all steps of this Grievance Procedure, the aggrieved nurse, if desired, may be accompanied by or represented by a nurse representative. 8.03 It is the mutual desire of the parties hereto that complaints of the nurses shall be adjusted as quickly as possible, and it is understood that a nurse has no grievance until she has first given the Unit Manager the opportunity of adjusting her complaint. Such complaint shall be discussed with the Unit Manager within ten (10) days after the circumstances giving rise to it have occurred or ought reasonably to have come to the attention of the nurse and failing settlement within five (5) days, it shall then be taken up as a grievance within ten (10) days following the Unit Manager's decision in the following manner and sequence: The nurse may submit a written grievance on the form set out in Appendix "A", signed by her, to the Unit Manager. The grievance shall identify the nature of the grievance and the remedy sought and should identify the provisions of the Agreement which are alleged to be violated. The Unit Manager will deliver her decision in writing within five (5) days of the submission of the grievance. Failing settlement, then: Within five (5) days following the decision in Step No. 1, the nurse may submit the written grievance to the Director of Resident Care who will deliver her decision, in writing, within five (5) days from the date on which the written grievance was presented to her. The parties may, if they so desire, meet to discuss the grievance at a time and place suitable to both parties. Failing settlement, then: Within ten (10) days of receiving the decision under Step 2, the grievance, in writing, may be referred to the Chief Executive Officer who shall call a meeting of the Grievance Committee within five (5) days of receipt of same. Within five (5) days following the meeting, the Chief Executive Officer shall reply, in writing, to the nurse and the Chairperson of the Grievance Committee. If the decision is unsatisfactory to the nurse, it may be referred to arbitration within fifteen (15) days and the Chief Executive Officer so notified, in writing.

  • Function of Joint Health and Safety Committee All incidents involving aggression or violence shall be brought to the attention of the Joint Health and Safety Committee. The Employer agrees that the Joint Health and Safety Committee shall concern itself with all matters relating to violence to staff.

  • Arbitration Board Where the parties agree to a Board of Arbitration, the party referring the grievance to arbitration shall also provide the name of that party’s nominee to the Board of Arbitration. Within ten (10) days thereafter, the other party shall answer by registered mail, indicating the name and address of its nominee to the Board of Arbitration. The selection of the Chair shall be in accordance with the list of arbitrators above.

  • Qualified Medical Child Support Order A child who would otherwise meet the eligibility requirements and is required to be covered by a Qualified Medical Child Support Order (QMCSO) is considered an eligible dependent.

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