For denial of expedited authorization decisions Sample Clauses

For denial of expedited authorization decisions. For cases in which a provider indicates, or INSURER determines, that following the standard timeframe could seriously jeopardize the enrollee’s life, or health, or ability to attain; maintain; or regain maximum function, INSURER shall make an expedited authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than three (3) working days after receipt of the request for service. 37 INSURER may extend said three-day period up to fourteen (14) calendar days if the enrollee requests an extension, or if the entity justifies (to the ADMINISTRATION upon request) the need for additional information and how the extension would be in the enrollee’s best interest.
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For denial of expedited authorization decisions. In cases in which a provider indicates to the TPA/HCO that following the standard timeframe could seriously jeopardize the enrollee’s life or health, or ability to attain, maintain, or regain maximum function, the TPA/HCO shall make an expedited authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than three (3) working days after receipt of the request for service. If the enrollee, or the provider, or the TPA/HCO justifies a need for additional information or if it is in the best interest of the enrollee, an extension up to 14 additional calendar days may be granted. The TPA/HCO agrees fully to cooperate with the Advisory Committee of the Commonwealth’s Medicaid Office set up as requested by 42 Code of Federal Regulations Part 431, which advises the Medicaid agency about health and medical care services. The ADMINISTRATION and the TPA shall coordinate any and all efforts geared at cooperating with said Advisory Committee to the extent permissible by law.
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Related to For denial of expedited authorization decisions

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  • Procedure for Determination of Entitlement to Indemnification 9.1 To obtain indemnification under this Agreement in connection with any Proceeding, and for the duration thereof, Indemnitee shall submit to the Company a written request, including therein or therewith such documentation and information as is reasonably available to Indemnitee and is reasonably necessary to determine whether and to what extent Indemnitee is entitled to indemnification. The Secretary of the Company shall, promptly upon receipt of any such request for indemnification, advise the Board in writing that Indemnitee has requested indemnification.

  • Indemnitee Rights on Unfavorable Determination; Binding Effect If any Reviewing Party determines that Indemnitee substantively is not entitled to be indemnified hereunder in whole or in part under applicable law, Indemnitee shall have the right to commence litigation seeking an initial determination by the court or challenging any such determination by such Reviewing Party or any aspect thereof, including the legal or factual bases therefor, and, subject to the provisions of Section 15, the Company hereby consents to service of process and to appear in any such proceeding. Absent such litigation, any determination by any Reviewing Party shall be conclusive and binding on the Company and Indemnitee.

  • Claims Procedure An Executive or Beneficiary (“claimant”) who has not received benefits under this Agreement that he or she believes should be distributed shall make a claim for such benefits as follows:

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