Handling of Grievances and Appeals Sample Clauses

Handling of Grievances and Appeals. The Contractor shall adhere to the following record keeping, monitoring, and review requirements: A. Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance, appeal, or expedited appeal. (42 C.F.R. § 438.416(a); Cal. Code Regs., tit. 9, § 1850.205(d)(1).) Each record shall include, but not be limited to: a general description of the reason for the appeal or grievance the date received, the date of each review or review meeting, resolution information for each level of the appeal or grievance, if applicable, and the date of resolution at each level, if applicable, and the name of the covered person whom the appeal or grievance was filed. (42 C.F.R. § 438.416(b)(1)-(6).) B. Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log. (Cal. Code Regs., tit. 9, § 1850.205(d)(2).) C. Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal. (Cal. Code Regs., tit. 9, § 1850.205(d)(3).) D. Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary. (Cal. Code Regs., tit. 9, § 1850.205(d)(5).) X. Xxxxxxx notice, in writing, to any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal. (Cal. Code Regs., tit. 9, § 1850.205(d)(6).) F. Maintain records in the grievance and appeal log accurately and in a manner accessible to the Department and available upon request to CMS. (42 C.F.R. § 438.416(c).)
Sample 1Sample 2Sample 3See All (15)
AutoNDA by SimpleDocs
Handling of Grievances and Appeals. The grievance and appeal procedures shall be governed by the following requirements:
Sample 1Sample 2Sample 3See All (4)
Handling of Grievances and Appeals. (42 CFR §438.406). i. In handling grievances and appeals, the Contractor shall give beneficiaries any reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. ii. The Contractor’s process for handling beneficiary grievances and appeals of adverse benefit determinations shall: a. Acknowledge receipt of each grievance and appeal. b. Ensure that the individuals who make decisions on grievances and appeals are individuals— i. Who, were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. ii. Who, if deciding any of the following, are individuals who have the appropriate clinical expertise, as determined by the Department, in treating the beneficiary’s condition or disease.
Sample 1
Handling of Grievances and Appeals. The Health Plan’s policies and procedures for handling Grievances and Appeals shall include the following requirements: a) The Health Plan shall provide the information specified at 42 CFR § 438.10(g)(1) about the Grievance and Appeals system to all Providers and subcontractors at the time they enter into a contract. b) The Health Plan shall give Enrollees any reasonable assistance in completing forms and taking other procedural steps including, but not limited to providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. c) The Health Plan shall acknowledge receipt of each Grievance and Appeal. d) The Health Plan shall ensure that individuals who make decisions on Grievances and Appeals are individuals who: (1) Were not involved in any previous level of review or decision- making; and (2) Are health care professionals who have the appropriate clinical expertise in treating the Enrollee’s condition or disease, as determined by IDHW, when deciding an Appeal of a denial that is based on Medical Necessity or lack thereof, or a Grievance regarding denial of expedited resolution of an Appeal, or a Grievance or Appeal that involves clinical issues. (3) Take into account all comments, documents, records, and other information submitted by the Enrollee or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination. e) The Health Plan’s Appeal Process shall: (1) Provide that oral inquiries seeking to appeal an Action are treated as Appeals to establish the earliest possible filing date, and are confirmed in writing unless the Enrollee or the Provider requests expedited resolution; (2) Provide the Enrollee a reasonable opportunity to present evidence and testimony, and make legal and factual arguments, in person as well as in writing (the Health Plan shall inform the Enrollee of the limited time available for this in the case of expedited resolution); (3) Provide the Enrollee and his or her representative opportunity, before and during the Appeals process, to examine the Enrollee’s case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the Health Plan (or at the direction of the Health Plan) during the Appeals process. This information must be provided free of charge and sufficiently in advance of the resolution timeframe; and (4) Include, as parties to th...
Sample 1
Handling of Grievances and Appeals. 43 9.5.1 General Requirements 43 9.5.2 Special Requirements for Appeals 44 9.6 Notice of Action 45 9.6.1 Language and Format Requirements 45 9.6.2 Content of Notice 45 9.6.3 Timing of Notice 45 9.7 Resolution and Notification 46 9.7.1 Specific Timeframes 47 9.7.2 Extension of Timeframes 47 9.7.3 Format of Notice 47 9.7.4 Content of Notice of Appeal Resolution 48 9.7.5 Requirements for State Fair Hearings 48 9.8 Expedited Resolution of Appeals 48 9.8.1 Punitive Action 48 9.8.2 Action Following Denial of a Request for Expedited Resolution 49 9.8.3 Failure to Make a Timely Decision 49
Sample 1

Related to Handling of Grievances and Appeals

  • Grievances and Appeals a. If you have questions about any pediatric dental services received, please first discuss the matter with your Dental Provider. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center. You can also email questions by accessing the “Contact Us” section of the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.

  • 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.

  • Submission of Grievances A. Any employee or group of employees shall have the right to present a grievance. No employee or group of employees shall be hindered from or disciplined for exercising this right. B. If any two (2) or more employees have essentially the same grievance they may, and if requested by the County must, collectively present and pursue their grievance if they report to the same immediate supervisor. C. If the grievant is a group of more than three (3) employees, the group shall, at the request of the County, appoint one (1) or two (2) employees to speak for the collective group. To be considered a grievant in a group grievance, each employee must be individually identified as a grievant when the grievance is submitted at Step 2.

  • Complaints and Appeals As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • 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.

  • Processing Grievances The Association Representative involved and the grieving supervisor shall not leave work or disrupt departmental routine to discuss grievances without first requesting permission from his/her immediate superior, which shall not be unreasonably withheld. The Association Representative and the grieving supervisor shall be allowed a reasonable amount of time during working hours while on the Appointing Authority's premises when a grievance is investigated or presented in Steps 1 and 2.

  • Types of Grievances (A) An Individual Grievance is a grievance initiated by the Union on behalf of an individual employee. (B) A Group Grievance is a grievance initiated by the Union on behalf of a group of employees similarly affected by the Employer’s actions. (C) A Policy Grievance is a grievance by the Union which may involve a matter of general policy or general application of the Collective Agreement. (D) A Union Grievance is a grievance which directly affects the Union. (E) An Employer Grievance is a grievance initiated by the Employer.

  • COMPLAINT AND GRIEVANCE PROCEDURE 9.01 Where a difference arises between the parties relating to the interpretation, application or administration of this Agreement, including any questions as to whether a matter is arbitrable, or where an allegation is made that this Agreement has been violated or whenever an employee who has completed the required probationary period and has been accepted by the Employer for employment in the permanent service, claims that he/she has been disciplined or discharged without reasonable cause, such difference, allegation or claim being hereinafter referred to as the grievance, the grievance procedure set forth below shall apply. 9.02 The Association shall name, appoint or otherwise select a Grievance Committee of no more than three (3) who shall be members of the Association and shall have reached at least the rank of First Class Fire Fighter and other advisors as deemed necessary at the expense of the Association. The Employer shall recognize and deal with the Grievance committee with respect to any matter or dispute which properly arises from a breach of the Collective Agreement from time to time during its term. This committee shall suffer no loss as a result of their attendance at such grievance meetings, hearings, etc. 9.03 No grievance will be considered where the circumstances giving rise to it occurred or originated more than ten (10) full working days before the submission of the grievance. Step 1 - An employee having a grievance will take the matter up through their Association representative. The President or designate shall contact Fire Management to seek a resolution. Step 2 - If the grievance is not settled within five (5) working days, the Association shall submit the matter in writing to the Fire Chief or designate within five (5) working days of receiving the reply from Step 1. The Fire Chief or designate shall render the written decision to the Association within five (5) working days after receiving the written grievance. In the context of this Article a working day shall be deemed to be Monday to Friday excluding designated holidays. Step 3 - If the reply of the Fire Chief is not acceptable to the Association the grievance may be referred to the Chief Administrative Officer (CAO) or the Director of Human Resources within five (5) working days of the written decision of the Fire Chief. The CAO or the Director of Human Resources, who together with the Fire Chief and any other advisors deemed necessary, shall meet with the Association Representatives within 5 working days to consider the grievance. Within five (5) working days of the aforesaid, the CAO or the Director of Human Resources will render a written reply to the employee and the Association. Step 4 - If no resolve is reached at Step 3, the matter shall be submitted to arbitration. Notice shall be given within 5 business days. The parties agree that, for the purposes of this collective agreement the words of the expedited arbitration provisions of the Labour Relations Act, 1995 as amended (Section 49), will be deemed to have been incorporated into this collective agreement. Accordingly and notwithstanding any other provisions of this article (the grievance/arbitration provisions); either party may refer a grievance to expedited arbitration in accordance with the provisions of Section 49. The parties further agree that neither party will raise any jurisdictional or other objection to the application of Section 49 to a grievance under this collective agreement as it pertains to the right to an expedited arbitration. Either party is entitled however, to raise any objection, with the arbitrator with respect to whether the provisions of Section 49 have been properly utilized in respect of any specific grievance (e.g. objections with respect to time limits etc.). Such an appointment by the Minister of Labour or his or her designate will be determined to be a joint appointment in accordance with Section 53(3) of the Fire Protection and Prevention Act. 9.04 Extensions to the time limits in 9.03 may not be unreasonably withheld. 9.05 The employee in all steps of the grievance procedure shall be confined to the grievance and redress sought as set forth in the written grievance initially filed as provided.

  • Submission of Grievance Information a. Upon appointment of the arbitrator, the appealing party shall, within five (5) days after notice of appointment, forward to the arbitrator, with a copy to the School Board, the submission of the grievance which shall include the following: 1. The issues involved. 2. Statement of the facts. 3. Position of the grievant. 4. The written documents relating to Section 5 of the grievance procedure.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!