EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION Sample Clauses

EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION. If a Member is not satisfied upon receiving the Final Internal Adverse Benefit Determination, he or she has four (4) months from receipt to request an external appeal through an Independent Review Organization (IRO). External review is available for appeals from an Adverse Benefit Determination or Final Adverse Benefit Determination that involves medical judgment (including, decisions based on the HMO’s requirements for Medical Necessity and appropriateness, heath care setting, level of care or effectiveness of a covered benefit as well as the HMO’s treatment is experimental /investigational or cosmetic. In order to request an external appeal, the Member must contact the HMO at the following address, fax and telephone numbers: HMO External Grievance Review X.X. Xxx 000000 Xxxxxxxxxx, XX 00000-0000 Fax: 000-000-0000 Toll-free: 0-000-000-0000 TTY: 711 Within five (5) business days of receipt of the Member’s request, the HMO will forward the Member’s request to a randomly assigned IRO. The HMO will forward the documentation pertaining to the denial to the IRO assigned and will simultaneously forward a list of the documents to the Member. The Member may submit additional information to the IRO for consideration in the external appeal. The IRO will notify the Member of its decision in writing within forty-five (45) days from the date of the IRO’s receipt of the request for external review. External appeals are for appeals involving Medical Necessity issues. Requests for expedited review may be made at any time in the appeals process. To request an expedited review of an Adverse Benefit Determination or Final Adverse Benefit Determination the Member may call Customer Services at 0-000-000-0000 (TTY: 711). Requests for expedited review should be made by telephone in order to avoid any mail delays. The HMO will promptly inform the Member and the Member’s provider if the request qualifies for expedited review. A Member is entitled to request an expedited review process at the time her or she receives an Adverse Benefit Determination which involves a medical condition for which the timeframe for completion of a standard internal review would seriously jeopardize the Member’s life or health or would jeopardize the Member’s ability to regain maximum function. A Member is also entitled to an expedited review process if in the opinion of a physician with knowledge of the Member’s condition, the delay from a standard pre-service review would subject the Member to severe ...
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EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION. If a Member is not satisfied upon receiving the Final Internal Adverse Benefit Determination, he or she has four (4) months from receipt to request an external appeal through an Independent Review Organization (IRO). External review is available for appeals from an Adverse Benefit Determination or Final Adverse Benefit Determination that involves medical judgment (including, decisions based on the HMO’s requirements for Medical Necessity, heath care setting, level of care or effectiveness of a covered benefit as well as whether the requested treatment is experimental /investigational or cosmetic or a rescission. In order to request an external appeal, the Member must contact the HMO at the following address, fax and telephone numbers: HMO External Grievance Review P.O. Box 779518 Harrisburg, PA 00000-0000 Fax: 000-000-0000 Toll-free: 0-000-000-0000 TTY: 711 Within five (5) business days of receipt of the Member’s request, the HMO will forward the Member’s request to a randomly assigned IRO. The HMO will forward the documentation pertaining to the denial to the IRO assigned and will simultaneously forward a list of the documents to the Member. The Member may submit additional information to the IRO for consideration in the external appeal. The IRO will notify the Member of its decision in writing within forty-five (45) days from the date of the IRO’s receipt of the request for external review.
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EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION. If a Member is not satisfied upon receiving the Final Internal Adverse Benefit Determination, he or she has one (1) year from receipt of the Notice of Final Adverse Benefit Determination to request an external appeal to the U.S. Office of Personnel Management (OPM) at the following mail address or email address, fax and telephone numbers: MSPP External Review National Healthcare Operations U.S. Office of Personnel Management 0000 X. Xxxxxx, XX Xxxxxxxxxx, XX 00000 e-mail: xxxx@xxx.xxx The Member may request external review after the expiration of the one (1) year period by providing a reasonable explanation for failing to request external review within one (1) year. The Member may phone OPM at the following numbers with questions about the right to external review: Fax: (000) 000-0000 Toll-free: 0-000-000-0000 External review is available for denials of coverage based on Medical Necessity including denials for services found to be experimental or investigational, cosmetic, provided in an inappropriate healthcare setting or level of care, provided out of network when available in network, not effective or not justified, or a rescission of coverage. A Member may also have the right to an external review if the plan fails to strictly comply with our internal appeals process and with state and federal requirements for internal appeals. External reviews are facilitated by the federal Office of Personnel Management (OPM). For denials based on the Member’s contract with the HMO, OPM will review and issue a binding determination. If the claim involves an issue of Medical Necessity and appropriateness, OPM will forward the appeal to an Independent Review Organization (IRO). OPM will notify Members that any additional information the Member submits to OPM within twenty (20) days of OPM’s acceptance of a request for external review is guaranteed to be considered. OPM will notify the Member of its binding decision in writing within thirty (30) days from the date OPM received of the request for external review. For external reviews involving medical judgment, an IRO will have fifteen (15) calendar days to render a decision after receiving the request from OPM. The IRO’s fifteen
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Related to EXTERNAL REVIEW OF A FINAL INTERNAL ADVERSE BENEFIT DETERMINATION

  • 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”).

  • 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.

  • 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, F.S.) and this agreement; nothing in this agreement, however, shall be deemed to diminish the rights of employees under applicable law. (B) When an allegation is made against an employee, the state will make every reasonable effort to ensure that the allegation and any related statements are reduced to writing, under oath, and signed. The written allegation shall be known as a complaint. (C) When an employee is to be questioned or interviewed concerning a complaint or allegation, the employee will be informed prior to the interview of the nature of the investigation and whether he is the subject of the investigation or a witness in an investigation. Employees shall be informed of the right to have a union representative in attendance at the interview and where requested, an employee shall be given 48 hours to contact, consult with, and secure the attendance of a representative at the interview. If he is the subject of the investigation, the employee and his representative will also be informed of each complaint or allegation against him and they shall be permitted to review all written statements and recordings made by the complainant and witnesses at least two hours prior to the commencement of the interview in accordance with section 112, F.S. In the event the written statement or recordings are such that additional review time is warranted, the employee may request, and be granted, additional time unless the request is made for the purposes of delay. Pursuant to section 112.533, F.S., the employee who is the subject of the investigation shall not disclose the contents to anyone other than his representative or attorney until the investigation is complete. (D) Interviews and questioning of employees shall be conducted in a professional manner. Statements from an employee shall not be taken in a coercive manner. (E) The formal interrogation of an employee shall comply with the provisions of section 112.532, F.S. The employee shall receive a copy of his written or recorded statement at no cost to the employee. No recording or transcription of the investigative interview will be made without the knowledge of all participants present at the interview. (F) In cases where the agency determines that the employee’s absence from the work location is essential to the investigation and the employee cannot be reassigned to other duties pending completion of the investigation, the employee shall be placed on administrative leave with pay. Such leave shall be in accordance with Chapter 60L-34, F.A.C. (G) Unless required by statute, no employee shall be required to submit to a polygraph test or any device designed to measure the truthfulness of his responses during an investigation of a complaint or allegation. (H) Only sustained findings may be inserted in personnel records. Unfounded findings shall not be inserted in permanent personnel records or referred to in performance reviews. (I) Internal investigations will ordinarily be completed within 45 days from the date the complaint is filed, unless circumstances necessitate a longer period. An investigation shall not exceed 120 days without the approval of the Agency Head or designee. Except in the case of a criminal investigation, the employee shall be notified in writing of any investigation that exceeds 120 days. (J) The employee under investigation shall be advised in writing of the results of the investigation at its conclusion. (K) The state will make a good faith effort to train persons who investigate charges against employees in the investigative rights reserved for those employees in the interest of avoiding infringement of those rights. (L) In the case of criminal, non-administrative internal investigation into the criminal misconduct of a sworn employee, the provisions of (B) through (K) shall not apply.

  • Adverse Selection No selection procedures adverse to the Noteholders were utilized in selecting the Receivables from those receivables owned by the Seller which met the selection criteria set forth in this Agreement.

  • No Adverse Selection No selection procedures adverse to Noteholders have been employed in selecting the Contracts.

  • Internal Resolution With respect to all disputes arising between the Parties under this Agreement, including, without limitation, any alleged breach under this Agreement or any issue relating to the interpretation or application of this Agreement, if the Parties are unable to resolve such dispute within thirty (30) days after such dispute is first identified by either Party in writing to the other, the Parties shall refer such dispute to the Chief Executive Officers of the Parties for attempted resolution by good faith negotiations within thirty (30) days after such notice is received.

  • 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.

  • Sxxxxxxx-Xxxxx; Internal Accounting Controls The Company and the Subsidiaries are in compliance with any and all applicable requirements of the Sxxxxxxx-Xxxxx Act of 2002 that are effective as of the date hereof, and any and all applicable rules and regulations promulgated by the Commission thereunder that are effective as of the date hereof and as of the Closing Date. The Company and the Subsidiaries maintain a system of internal accounting controls sufficient to provide reasonable assurance that: (i) transactions are executed in accordance with management’s general or specific authorizations, (ii) transactions are recorded as necessary to permit preparation of financial statements in conformity with GAAP and to maintain asset accountability, (iii) access to assets is permitted only in accordance with management’s general or specific authorization, and (iv) the recorded accountability for assets is compared with the existing assets at reasonable intervals and appropriate action is taken with respect to any differences. The Company and the Subsidiaries have established disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) for the Company and the Subsidiaries and designed such disclosure controls and procedures to ensure that information required to be disclosed by the Company in the reports it files or submits under the Exchange Act is recorded, processed, summarized and reported, within the time periods specified in the Commission’s rules and forms. The Company’s certifying officers have evaluated the effectiveness of the disclosure controls and procedures of the Company and the Subsidiaries as of the end of the period covered by the most recently filed periodic report under the Exchange Act (such date, the “Evaluation Date”). The Company presented in its most recently filed periodic report under the Exchange Act the conclusions of the certifying officers about the effectiveness of the disclosure controls and procedures based on their evaluations as of the Evaluation Date. Since the Evaluation Date, there have been no changes in the internal control over financial reporting (as such term is defined in the Exchange Act) of the Company and its Subsidiaries that have materially affected, or is reasonably likely to materially affect, the internal control over financial reporting of the Company and its Subsidiaries.

  • 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”):