Internal Appeals Sample Clauses

Internal Appeals a. If a Member is not satisfied with any HDS adverse benefit determination, HDS payment, HDS decision, or other HDS action or omission related to the HDS Plan, Member may appeal by submitting a written request to the HDS employee designated as the HDS Appeals Manager. HDS must receive the appeal within one year from the date of the action, omission, or decision being contested. If the appeal concerns a benefit coverage or payment dispute, HDS must receive the appeal within one year from the date of the notice in which HDS first informed the Member or Subscriber of the denial or limitation on a claim for benefits. Requests that do not comply with the requirements of the appeals process will not be recognized or treated as an appeal by HDS.
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Internal Appeals. 1. Filing an Internal Appeal If the Enrollee disagrees with the Contractor’s decision, the Enrollee may file an internal Appeal by writing, faxing, or calling the Contractor within 60 calendar days of the receipt of the written denial notice. The Enrollee must follow an oral filing with a written signed Appeal within the 60-day limit, unless the Enrollee requests an expedited appeal decision in accordance with Section 2.9.B.2.b. A Provider acting on behalf of an Enrollee, and with the Enrollee’s written consent, may file an internal Appeal. The Enrollee may also file an internal Appeal through the Social Security Administration or the Railroad Retirement Board, which will forward the Appeal to the Contractor. The 60-day limit may be extended at the discretion of the Contractor. Except for the circumstances described in Subsection 2.9(C)(2), an Enrollee must first exhaust the Contractor’s internal Appeal process under Subsection 2.9(B) before the Enrollee can proceed with an external Appeal under Subsection 2.9(C).
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Internal Appeals 
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Related to Internal Appeals

  • 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.

  • External Arbitration Procedures Any arbitration initiated under this LGIA shall be conducted before a single neutral arbitrator appointed by the Parties. If the Parties fail to agree upon a single arbitrator within ten (10) Calendar Days of the submission of the dispute to arbitration, each Party shall choose one arbitrator who shall sit on a three-member arbitration panel. The two arbitrators so chosen shall within twenty (20) Calendar Days select a third arbitrator to chair the arbitration panel. In either case, the arbitrators shall be knowledgeable in electric utility matters, including electric transmission and bulk power issues, and shall not have any current or past substantial business or financial relationships with any party to the arbitration (except prior arbitration). The arbitrator(s) shall provide each of the Parties an opportunity to be heard and, except as otherwise provided herein, shall conduct the arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association (“Arbitration Rules”) and any applicable FERC regulations; provided, however, in the event of a conflict between the Arbitration Rules and the terms of this Article 27, the terms of this Article 27 shall prevail.

  • Internal Controls The Company shall maintain a system of internal accounting controls sufficient to provide reasonable assurances that: (i) transactions are executed in accordance with management’s general or specific authorization; (ii) transactions are recorded as necessary in order to permit preparation of financial statements in accordance with GAAP and to maintain accountability for assets; (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 existing assets at reasonable intervals and appropriate action is taken with respect to any differences.

  • Accounting Controls The Company and its Subsidiaries maintain systems of “internal control over financial reporting” (as defined under Rules 13a-15 and 15d-15 under the Exchange Act Regulations) that comply with the requirements of the Exchange Act and have been designed by, or under the supervision of, their respective principal executive and principal financial officers, or persons performing similar functions, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with GAAP, including, but not limited to, 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. Except as disclosed in the Registration Statement, the Pricing Disclosure Package and the Prospectus, the Company is not aware of any material weaknesses in its internal controls. The Company’s auditors and the Audit Committee of the Board of Directors of the Company have been advised of: (i) all significant deficiencies and material weaknesses in the design or operation of internal controls over financial reporting which are known to the Company’s management and that have adversely affected or are reasonably likely to adversely affect the Company’ ability to record, process, summarize and report financial information; and (ii) any fraud known to the Company’s management, whether or not material, that involves management or other employees who have a significant role in the Company’s internal controls over financial reporting.

  • Internal Practices To make Business Associate’s internal practices, books and records relating to the use and disclosure of PHI received from County, or created or received by Business Associate on behalf of County, available to County or to the Secretary of the U.S. Department of Health and Human Services in a time and manner designated by County or by the Secretary, for purposes of determining County compliance with the HIPAA regulations.

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