External Independent Medical Review Sample Clauses

External Independent Medical Review. If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service.
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External Independent Medical Review. 1. The Member may request review by a certified independent review organization of an adverse determination if: a. the Member has completed the Complaints and Appeals hearing process and the adverse determination has been upheld, or b. the HMO has exceeded the timelines for Complaints and Appeals hearings set forth above without good cause and without reaching a decision. 2. Not later than the third business day after the date the HMO receives a request for an independent medical review, HMO will provide to the Independent Medical Review Organization designated by the Office of the Insurance Commissioner: a. the medical records of the Member that are relevant to the review; b. documents used by HMO in making the determination to be reviewed; c. a list of each Physician or Health Care Professional who has provided care to the Member and who may have medical records relevant to the Appeal; d. the treating Provider’s recommendations; and e. the terms and conditions of coverage of the Member’s plan. 3. HMO will make available to the Member and/or the Member’s treating Provider copies of all materials provided to the independent review organization. The Member and the Member’s treating Provider will make available to HMO any information that they provided to the independent review organization in support of their appeal. 4. If the independent medical review request involves services which the Member is currently receiving (for example, the Member is currently hospitalized and HMO has determined that coverage for continued inpatient care is not Medically Necessary) HMO will continue to provide coverage for the services until the independent review organization makes their decision. If the independent review organization decision upholds the HMO’s determination, the Member will be responsible for the cost of the continued health care services. 5. If the independent review organization’s determination overturns the HMO’s decision the HMO will promptly comply with the final determination. 6. The Member is not responsible for any portion of the independent review organization’s charges.
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External Independent Medical Review 
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Related to External Independent Medical Review

  • External Review In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact XxXxx’s Member Engagement Center.

  • Quoted Investments External Review With respect to Portfolio Investments (including Cash Equivalents) for which market quotations are readily available, the Borrower shall, not less frequently than once each calendar week, determine the market value of such Portfolio Investments which shall, in each case, be determined in accordance with one of the following methodologies (as selected by the Borrower):

  • Unquoted Investments External Review With respect to Eligible Portfolio Investments for which market quotations are not readily available (“Unquoted Investments”):

  • Evaluation Committee 16.2.1 The Association and the Board agree to establish a standing joint Evaluation Development Committee for the purpose of regularly reviewing the effectiveness of the policy, procedure and process, including the evaluation instrument, for the evaluation of teachers in the District and to provide recommendations to the Superintendent and Board by April 30.

  • TRANSITION COMMITTEE A transition committee comprised of the employee representatives and the employer representatives, including the Crown, will be established by January 31, 2016 to address all matters that may arise in the creation of the Trust.

  • Technical Advisory Committee (TAC The goal of this subtask is to create an advisory committee for this Agreement. The TAC should be composed of diverse professionals. The composition will vary depending on interest, availability, and need. TAC members will serve at the CAM’s discretion. The purpose of the TAC is to: • Provide guidance in project direction. The guidance may include scope and methodologies, timing, and coordination with other projects. The guidance may be based on: o Technical area expertise; o Knowledge of market applications; or o Linkages between the agreement work and other past, present, or future projects (both public and private sectors) that TAC members are aware of in a particular area. • Review products and provide recommendations for needed product adjustments, refinements, or enhancements. • Evaluate the tangible benefits of the project to the state of California, and provide recommendations as needed to enhance the benefits. • Provide recommendations regarding information dissemination, market pathways, or commercialization strategies relevant to the project products. The TAC may be composed of qualified professionals spanning the following types of disciplines: • Researchers knowledgeable about the project subject matter; • Members of trades that will apply the results of the project (e.g., designers, engineers, architects, contractors, and trade representatives); • Public interest market transformation implementers; • Product developers relevant to the project; • U.S. Department of Energy research managers, or experts from other federal or state agencies relevant to the project; • Public interest environmental groups; • Utility representatives; • Air district staff; and • Members of relevant technical society committees. • Prepare a List of Potential TAC Members that includes the names, companies, physical and electronic addresses, and phone numbers of potential members. The list will be discussed at the Kick-off meeting, and a schedule for recruiting members and holding the first TAC meeting will be developed. • Recruit TAC members. Ensure that each individual understands member obligations and the TAC meeting schedule developed in subtask 1.11. • Prepare a List of TAC Members once all TAC members have committed to serving on the TAC. • Submit Documentation of TAC Member Commitment (such as Letters of Acceptance) from each TAC member. • List of Potential TAC Members • List of TAC Members • Documentation of TAC Member Commitment

  • JOINT LABOR MANAGEMENT COMMITTEE The parties agree that they will continue the Joint Labor-Management Committee to discuss matters of mutual interest relating to the employees covered by this Agreement. Topics for the Joint Labor-Management Committee may include, but are not limited to, Professional Development, Incentive Pay, etc. The Committee shall meet quarterly or as mutually agreed by the co-chairs. The President of CWA or designee and the Director of Human Resources or designee shall serve as co-chairs.

  • School Board Review The School Board reserves the right to review any decision issued under Level I or Level II of this procedure provided the School Board or its representative notifies the parties of its intention to review within ten (10) days after the decision has been rendered. In the event the School Board reviews a grievance under this section, the School Board reserves the right to reverse or modify such decision.

  • LABOR MANAGEMENT COMMITTEE Section 1. In order to facilitate communication between labor and management, a Labor Management Committee consisting of the Department Head and/or his designated alternate, the Assistant Chief of Police and two (2) Team Managers, and three (3) representatives of the Lincoln Police Union, along with at least one (1) Team Representative, will make up the Labor Management Committee. The Department Head will designate management personnel and the Union shall select Union representatives. Members will serve at the pleasure of the Department Head or Union President, depending upon who the member represents. Members will serve and be replaced on a staggered system (approximately three (3) year limit) depending upon the schedule agreed upon by the Department Head and the Union President. Section 2. Each Team area will be represented by a member of any rank to serve as spokesperson for that area. They will meet at least one week prior to the monthly Labor Management Committee meeting to formulate the common areas of interest and to elect a spokesperson to present the items in writing to the Labor Management Committee. Payment for attending this meeting will be at the discretion of the Department Head. Spokesperson will be chosen on a rotating basis. Team representatives will be picked by a vote of the Team members that they are representing. Section 3. The Labor Management Committee may discuss any area of the Department, with limitation only on those areas already under agreement between the City and the Union. The agenda will be based on the problem areas brought to the attention of the Committee by the Team Representatives and on any area representative members of Labor Management feel need to be discussed. Topics for discussion will be posted on the Union bulletin board and disseminated to Labor Management Committee members at least one (1) week prior to the monthly meeting. Section 4. Membership is subject to change through attrition and elected office, however, a one (1) week notice must be given to the Committee to afford the new member(s) voting privileges. Section 5. Realizing that communication is the key element to the smooth operation of any organization, the Labor Management Committee will xxxxxx an element of cooperation and unity of organizational members, be they labor or management. Section 6. Meetings shall be held at least once per calendar month. Additional meetings may be scheduled by mutual agreement of the Committee and the Department Head. Section 7. A quorum shall consist of two (2) members from labor and two (2) members from management.

  • Internal Review The Borrower shall conduct internal reviews to determine the value of all Eligible Portfolio Investments at least once each calendar week which shall take into account any events of which the Borrower has knowledge that adversely affect the value of any Eligible Portfolio Investment (each such value, an “Internal Value”).

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