EXTERNAL PEER REVIEW Sample Clauses

EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Facility may submit a written request for an External Peer Review if Facility is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Facility can request a review by an external peer review organization to review the medical record in dispute. Facility will normally be notified of the determinations made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Facility and BCBSM. If BCBSM’s findings are upheld on appeal, Facility will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of Facility’s right to appeal any Medical Necessity issues to the Michigan Office of Financial and Insurance Services or to initiate an action on those issues in an appropriate civil court. Facility’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Manager, Facility Utilization Review Mail Code J105 Blue Cross Blue Shield of Michigan 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 For Individual Claims disputes, a request for External Peer Review shall be mailed to: Conference Coordination Unit Mail Code 0000 Xxxx Xxxxx Xxxx Xxxxxx xx Xxxxxxxx 000 X. Xxxxxxxxx Xxxx. Xxxxxxx, XX 00000-0000 INTERNAL REVIEW COMMITTEE For disputes involving administrative and/or billing and coding issues, Facility may submit a written request for a review by the BCBSM Internal Review Committee which is composed of three members of BCBSM senior management. The request for an IRC hearing shall specify the reasons why the BCBSM policy in dispute is inappropriate or has been wrongly applied, and shall be submitted in writing within 30 days of receipt of BCBSM’s response to the Managerial- Level Review Conference. Within 60 days of the request, a meeting will be held. Facility, or Facility’s representative upon Xxxxxxxx’s writ...
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EXTERNAL PEER REVIEW. For disputes involving issues of Medical Necessity that are resultant from medical record reviews, Provider may submit a written request for an External Peer Review if he/she is dissatisfied with the previous level of appeal. Within 30 days of the Managerial-Level Review Conference determination, Provider can request a review by an external peer review organization to review the medical record(s) in dispute. Provider will normally be notified of the determination(s) made by the review organization within 60 days of submission of the records to the peer review organization. Such determination will be binding upon Provider and BCBSM. If BCBSM’s findings are upheld on appeal, Provider will pay the review costs associated with the appeal. If BCBSM’s findings are reversed by the external peer review organization, BCBSM will pay the review costs associated with the appeal. If BCBSM’s findings are partially upheld and partially reversed, the parties will share in the review costs associated with the appeal, in proportion to the results as measured in findings upheld or reversed. This appeal step ends the appeal process for all Medical Necessity issues arising from any medical record review and operates as a waiver of Provider’s right to initiate an action on those issues in a state court. Provider’s request for External Peer Review for a dispute involving medical record audit results shall be mailed to: Blue Cross Blue Shield of Michigan Manager, Professional Utilization Review Mail Code J103
Sample 1
EXTERNAL PEER REVIEW. In the mid 70s, the Private Companies Practice Section (PCPS) was founded by the American Institute of CPAs (AICPA) to establish a voluntary quality assurance program for CPA firms. There are requirements for membership in the section, which include mandatory continuing education for each member of the professional staff and a key element is a tri-annual independent review of a firm’s quality control system in its practice of public accounting. Xxxxxxx & Xxxxxxx has been a member of the section from inception. The peer review aspect has evolved from being voluntary to mandatory and Xxxxxxx & Xxxxxxx is in full compliance with the requirements of having a tri-annual review. In the peer reviewer’s latest report dated October 30, 2017, our reviewing firm gave a rating of “pass” which is the highest form of assurance they can render on the system of quality control for our accounting and audit practice. A copy of the report on our most recent external quality control review is provided on the next page. The quality control review included a review of specific government engagements. No letter of comment was received as a result of this review. We are quite proud to be one of the few Southeast based firms to have undergone this review and to have received such an excellent opinion from a large reputable national firm.
Sample 1

Related to EXTERNAL PEER REVIEW

  • Peer Review Dental Group, after consultation with the Joint ----------- Operations Committee, shall implement, regularly review, modify as necessary or appropriate and obtain the commitment of Providers to actively participate in peer review procedures for Providers. Dental Group shall assist Manager in the production of periodic reports describing the results of such procedures. Dental Group shall provide Manager with prompt notice of any information that raises a reasonable risk to the health and safety of Group Patients or Beneficiaries. In any event, after consultation with the Joint Operations Committee, Dental Group shall take such action as may be reasonably warranted under the facts and circumstances.

  • External Audit (a) The Beneficiary or the Executing Agency, as the case may be, shall present to the Bank, during the period of Project execution and within the deadlines and with the frequency provided in the Special Conditions of this Agreement, the Project’s financial statements and other reports, and any additional financial information relating thereto that the Bank may request, in accordance with accounting principles and standards acceptable to the Bank.

  • 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.

  • External monitoring The external monitoring and audit referred to in Articles 11.1, 11.2, 11.3 and 11.4 of the Regulation shall not in any way relieve the National Focal Point or the Programme Operator of their obligations under the legal framework regarding monitoring of the Programme and/or its projects, financial control and audit.

  • Internal Investigations (A) The parties recognize that Florida Highway Patrol personnel occupy a special place in American society. Therefore, it is understood that the state has the right to expect that a professional standard of conduct be adhered to by all Florida Highway Patrol personnel regardless of rank or assignment. Since internal investigations may be undertaken to inquire into complaints of Florida Highway Patrol misconduct, the state reserves the right to conduct such investigations to uncover the facts in each case, but expressly agrees to carefully guard and protect the rights and dignity of accused personnel. In the course of an internal investigation, the investigative methods employed will be consistent with the law (including but not limited to section 112.532, Florida Statutes) and this agreement; nothing in this agreement, however, shall be deemed to diminish the rights of employees under applicable law.

  • 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.

  • Evaluation Committee A The Association and the Board agree to establish a standing joint Evaluation Development Committee for the purpose of establishing the procedure and process, including the evaluation instrument, for the evaluation of teachers in the District and to regularly review the effectiveness of the procedure and process, including the evaluation instrument, for the evaluation of teachers in the District.

  • Rating Impact on Student Learning Growth ESE will provide model contract language and guidance on rating educator impact on student learning growth based on state and district-determined measures of student learning. Upon receiving this model contract language and guidance, the parties agree to bargain with respect to this matter.

  • Joint Job Evaluation Committee The parties entered into agreement December 17, 1992, to ensure the Joint Gender- Neutral Job Evaluation Plan remains current and operational and to that end endorsed the Joint Gender-Neutral Job Evaluation Maintenance Agreement. The parties agree that a guiding principle for the Committee is that there shall be no discrimination between male and female employees wherein a person of one sex is paid more than a person of the other sex for similar or substantially similar work.

  • Internal Control Effective control and accountability must be maintained for all cash, real and personal property, and other assets. Grantee must adequately safeguard all such property and must provide assurance that it is used solely for authorized purposes. Grantee must also have systems in place that provide reasonable assurance that the information is accurate, allowable, and compliant with the terms and conditions of this Agreement. 2 CFR 200.303.

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