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: Xxxxx Vision 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 ERISA RIGHTS 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: Receive Information About the Plan and Benefits 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...
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:‌‌‌ Xxxxx Vision 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. 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: Xxxxx Vision Quality Assurance Department
Sample 1

Related to Expedited Medical Necessity Appeal

  • Expedited Appeal An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, or any other urgent matter will be handled on an expedited basis. An expedited Appeal is not available for retrospective reviews. For an expedited Appeal, Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal. Your Provider and a clinical peer reviewer may exchange information by telephone or fax. An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two

  • 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.

  • 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. Complaints 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.

  • 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:

  • Grievance Commissioner The Employer and Union may mutually agree in writing to invoke the Commissioner Process rather than proceed to arbitration as set out in this Collective Agreement. All cases referred to arbitration where an employee has a grievance concerning discipline will only be referred to a Grievance Commissioner if the Employer and the Union agree in writing on all the facts. The parties may also agree to group grievances before a single Grievance Commissioner. A Grievance Commissioner (where more than one, acting in rotation) will set aside such time as may be requested by the Employer and the Union to consider and determine grievances referred to them. A Grievance Commissioner shall have the same powers and be subject to the same limitations as a Board of Arbitration hereunder, save and except as expressly provided in 9.18 to 9.22 hereof.

  • 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.

  • Expedited Arbitration Procedures If the issue to be resolved through the negotiations referenced in Section 14.2 directly and materially affects service to either Party's end user customers, then the period of resolution of the dispute through negotiations before the dispute is to be submitted to binding arbitration shall be five (5) Business Days. Once such a service affecting dispute is submitted to arbitration, the arbitration shall be conducted pursuant to the expedited procedures rules of the Commercial Arbitration Rules of the American Arbitration Association (i.e., rules 53 through 57).

  • Expedited Arbitration (a) The Parties may by mutual agreement refer to expedited arbitration any outstanding grievances considered suitable for this process, and shall set dates and locations for hearings of groups of grievances considered suitable for expedited arbitration.

  • Contractor Hearing Board 1. If there is evidence that the Contractor may be subject to debarment, the Department will notify the Contractor in writing of the evidence which is the basis for the proposed debarment and will advise the Contractor of the scheduled date for a debarment hearing before the Contractor Hearing Board.

  • 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.

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