External Review of Grievances Sample Clauses

External Review of Grievances. You may pursue an External Appeal if You are not satisfied with Our Appeal decision. An Independent Review Organization ("IRO") is available for Appeals that involve an Adverse Determination of any of the following. (A) a Medically Necessary Service. (B) a Utilization Review Determination. (C) the experimental or investigational nature of a proposed Health Service.
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External Review of Grievances. A Member may file a written request for an external review due to an adverse utilization review determination, an adverse determination of medical necessity, or a determination made by WHP or an agent of WHP that a proposed service by the treating Physician is Experimental/ Investigational. The request for an external review must be filed within forty-five (45) days after the Member is notified of the result of the Grievance. WHP will appoint an IRO certified by the Indiana Department of Insurance. WHP will be responsible for all costs associated with the review except for a $25 filing fee to be paid by the Member. WHP will cooperate with the IRO by promptly providing any information requested by the IRO. A Member who requests an external review is not subject to retaliation for exercising their right to appeal. A Member may use the assistance of other individuals including physicians, attorneys, friends, and family members throughout the review process and may submit additional information relating to the proposed service throughout the review process. A Member is expected to cooperate with the IRO by providing any requested medical information or authorizing the release of necessary medical information. Based on information gathered from the Member or the Member’s designee, WHP, the treating Physician and any additional information that the organization considers necessary and appropriate, the IRO will make a decision within ten (10) business days from the date the request is filed. If the Grievance is related to an illness, a disease, a condition, an injury or disability that would seriously jeopardize the Member’s life, health or ability to reach and maintain maximum function, the IRO will make a decision within seventy-two (72) hours of the time the expedited Appeal is filed. The IRO’s decision is binding upon WHP.
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Related to External Review of Grievances

  • 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.

  • Grievance A grievance is an alleged violation, misinterpretation, or misapplication of the terms of the negotiated agreement between the Board and the Association.

  • Disciplinary Grievances If the grievance is not resolved at Step 2, the Union may file a request for mediation with the Public Employment Relations Commission (PERC) in accordance with WAC 000-00-000, with a copy to the Office of Financial Management/SHR/Labor Relations Section (OFM/SHR/LRS) and the Human Resources Office within fifteen (15) days of receipt of the Step 2 decision. In addition to all other filing requirements, the request must include a copy of the grievance and all previous responses.

  • Policy Grievance – Union Grievance The Union may institute a grievance alleging a general misinterpretation or violation of this Agreement by the Employer by submitting a written grievance at Step No. 1 within twenty (20) days after the circumstances have occurred. This section shall not apply to disciplinary grievances or application of competitive clauses under this Agreement.

  • Settling of Grievances An xxxxxxx effort shall be made to process and settle grievances fairly and promptly in the following manner: It is agreed that an Employee has no grievance until he/she has first given his/her immediate Supervisor an opportunity to adjust his/her complaint within fourteen (14) calendar days of its occurrence or when they ought to have become aware of it. The Employee may request to meet with their Supervisor and is permitted to have a co-worker from their department present at the meeting. Prior approval is required to attend the meeting. The Employee has the option of making a written submission as an alternative to the meeting. The Employer will provide a written response to the complaint and if no satisfactory answer is received within seven (7) calendar days from the time it was first discussed with the Employee’s immediate Supervisor, the Employee may proceed to Step 1 of the grievance procedure. Step 1 Failing satisfactory settlement at the complaint stage the Union may present the grievance to the appropriate Supervisor within seven (7) calendar days following the decision at the complaint stage. The grievance shall be in writing on a mutually approved form and shall include the nature of the grievance, the redress sought and the section or sections of the agreement that are alleged to have been violated. The Supervisor shall deliver his/her decision in writing within seven (7) calendar days following the presentation of the grievance to him/her. Step 2 Failing satisfactory settlement at Step 1, the Union may present the grievance to the Administrator, or designate, in writing within seven (7) calendar days following receipt of the decision at Step 1. A meeting will be held within seven (7) calendar days from receipt of the grievance between the Administrator, or designate, and the Union. The decision of the Administrator, or designate, shall be delivered in writing within seven (7) calendar days of the meeting. Step 3 Failing satisfactory settlement at Step 2, either party may refer the grievance to arbitration within thirty (30) calendar days following receipt of the decision at Step 2.

  • ADJUSTMENT OF GRIEVANCES 8.01 (a) It is the mutual desire of the parties hereto that complaints of employees be adjusted as quickly as possible. To this end it is agreed that periodic meetings will be held between the Company and the Union to discuss the interpretation and administration of this Agreement. 8.01 (b) It is agreed that no grievance shall be processed which usurps the rights of Management. 8.01 (c) It is generally understood that an employee has no grievance until they have given their Xxxxxxx an opportunity to adjust the complaint. This may be done during working hours. (a) The Union shall arrange for the election from its working membership at each camp, by the members therein, of a Union Grievance Committee of three (3), headed by a Union Xxxxxxx who shall act as spokesperson for the Committee. In the absence of the Xxxxxxx the Company will recognize a delegated member of the Grievance Committee as spokesperson. Immediately after an election, the Union Grievance Committee in the camp will notify the xxxxxxx in writing as to the names of the Union Xxxxxxx and the members of the Union Grievance Committee elected and the xxxxxxx will acknowledge in writing the receipt of such notice. The Company xxxxxxx shall not be required to recognize either the Union Xxxxxxx or the Union Grievance Committee until such time as this procedure is carried out. (b) It is agreed that there shall be no discrimination exercised in any manner towards the Stewards or Union Grievance Committee. 8.03 A grievance under the provisions of this Agreement is defined to be any differences between the parties or between the Company and employees covered by this Agreement involving the interpretation, application, administration or alleged violation of any of the provisions of this Agreement. 8.04 Grievances as defined above may be taken by the employee, by the Union Xxxxxxx or the Union representative having jurisdiction directly to the employee's immediate supervisor for adjustment outside of working hours. The grievance shall be presented without undue delay. Any grievance submitted to the xxxxxxx, in accordance with this procedure, in writing, will be disposed of by the xxxxxxx in writing. Where a grievance has been submitted in writing, it will be dealt with in writing at all stages thereafter. Failing a satisfactory adjustment within forty-eight (48) hours, then,

  • Grievance Mediation Nothing in this Article precludes the Parties from mutually agreeing to grievance mediation during any stage of the grievance procedure. The agreement shall be made in writing and stipulate the name of the person and the time line for grievance mediation to occur.

  • 000 GRIEVANCE PROCEDURE 7. 100 It is agreed that it is the spirit and intent of this Agreement to adjust grievances promptly. All grievances, including discharge for just cause, but not those pertaining to jurisdictional disputes that may arise on any work covered by this Agreement, must be initiated within fifteen (15) working days of the incident by either the employee in Step I or the Local Union in Step II and shall be handled in the following manner:

  • Denial of Grievance Failure by the School Board or its representative to issue a decision within the time periods provided herein shall constitute a denial of the grievance and the employee may appeal it to the next level.

  • Settlement of Grievances The applicable procedures of this Agreement shall be followed for the settlement of all grievances. All grievances shall be considered carefully and processed promptly.

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