Managed Care Process Sample Clauses

Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization written notification and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Appeals Procedures Section).
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Managed Care Process. The Medical Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, SHL will complete the Prior Authorization written notification and send a copy to the Provider and the Insured. This form will specify approved services and supplies. Prior Authorization is not a guarantee of payment for Covered Services. The final decision as to whether any care should be received is between the Insured and the Provider. If SHL denies a request by an Insured and/or Provider for Prior Authorization of a service, the Insured or his Authorized Representative may appeal the denial to the Grievance Review Committee (see the Appeals Procedures Section).
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Managed Care Process. The Medical Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission.
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Managed Care Process. This section tells you about HPN’s Managed Care Program and which Covered Services require Prior Authorization. HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps direct the patient to the most appropriate setting to provide healthcare in a cost-effective manner. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together.  All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services as defined in this AOC, or other Covered Services provided by a Non-Plan Provider that are Prior Authorized by HPN’s Managed Care Program including any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:
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Managed Care Process.  It is the Insured's responsibility to verify Prior Authorization has been obtained for any Covered Services requiring Prior Authorization and to comply with all other rules of SHL’s Managed Care Program. The Medical Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission.
Sample 1
Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission.
Sample 1
Managed Care Process. The Dental Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine: • If the services are Medically Necessary and/or appropriate. • The appropriateness of the proposed setting. • The required duration of treatment or admission. The final decision as to whether any care should be received is between the Insured and the Provider. If SHL denies a request by an Insured and/or Provider, the Insured or his Authorized Representative may appeal the denial to the Grievance Review Committee (see the Appeals Procedures Section).
Sample 1
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Managed Care Process.  Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure by the Member to comply with the rules of HPN’s Managed Care Program means the Member will be responsible for costs of services received. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Section 10, Appeals Procedures).
Sample 1
Managed Care Process. All emergency admissions are reviewed Retrospectively to determine if the treatment received was Medically Necessary and appropriate and was for Emergency Services as defined in this AOC. If such Emergency Services are provided by Non-Plan Providers, all Medically Necessary professional, Inpatient or outpatient Emergency Services will be Covered Services.
Sample 1

Related to Managed Care Process

  • Complaints Process The School shall establish and adhere to a process for resolving public complaints which shall include an opportunity for complainants to be heard. The final administrative appeal shall be heard by the School's Governing Board, except where the complaint pertains to a possible violation of any law or term under this Contract. The complaints process shall be readily accessible from the School’s website, as described in Section 11.4.1.

  • CENTRAL GRIEVANCE PROCESS The following process pertains exclusively to grievances on central matters that have been referred to the central process. In accordance with the School Boards Collective Bargaining Act central matters may also be grieved locally, in which case local grievance processes will apply.

  • Grievance Process (a) Either party, with the agreement of the other party, may submit a grievance to Grievance Mediation at any time within ten (10) working days after the Employer’s decision has been rendered at the step prior to arbitration. Where the matter is so referred, the mediation process shall take place before the matter is referred to Arbitrator. (b) Grievance Mediation shall be scheduled within twenty (20) working days of the grievance being submitted to mediation, or longer period as agreed by the parties. (c) No matter may be submitted to Grievance Mediation which has not been properly carried through the grievance procedure, provided that the parties may extend the time limits fixed in the grievance procedure. (d) The parties shall agree on a mediator. (e) Proceedings before the Mediator shall be informal. Accordingly, the rules of evidence will not apply, no record of the proceedings shall be made and legal counsel shall not be used by either party, unless otherwise mutually agreed. (f) If possible, an agreed statement of facts will be provided to the Mediator, and if possible, in advance of the Grievance Mediation Conference. (g) The Mediator will have the authority to meet separately with either party. (h) If no settlement is reached within five (5) working days following Grievance Mediation, the parties are free to submit the matter to Arbitration in accordance with the provisions of the collective agreement. In the event that a grievance which has been mediated subsequently proceeds to arbitration, no person serving as the Mediator may serve as an Arbitrator, unless otherwise mutually agreed. Nothing said or done by the mediator may be referred to Arbitration. (i) The Union and Employer will share the cost of the Mediator, if any.

  • Grievance Processing Union stewards or Union officials shall be permitted to have time off without loss of pay for the investigation and processing of grievances and arbitrations. Requests for such time off shall be made in advance and shall not be unreasonably denied. The Union will furnish the Employer with a list of Union stewards and their jurisdictions. The Union shall delineate the jurisdiction of Union stewards so that no xxxxxxx need travel between work locations or sub-divisions thereof while investigating grievances. Grievants shall be permitted to have time off without loss of pay for processing their grievances through the contractual grievance procedure, except that for class action grievances no more than three (3) grievants shall be granted such leave.

  • Consultative Process This Agreement recognises a commitment of the parties to develop working arrangements which will bring success to the operations of the Company through the ability to implement flexible work arrangements to meet the requirements of customers and the personal, study or family commitments of employees.

  • Selection Process The Mortgage Loans were selected from among the outstanding one- to four-family mortgage loans in the Seller's portfolio at the related Closing Date as to which the representations and warranties set forth in Subsection 9.02 could be made and such selection was not made in a manner so as to affect adversely the interests of the Purchaser;

  • Process a. The grievance shall be referred to one of the following arbitrators: i. Xxxx Xxxxx ii. Xxxxx Xxxxxx iii. Xxxxx Xxxxxxxx

  • Claims Process We intend to appoint the senior trustee as the authorized representative to take action on behalf of holders of each series of the notes under the guarantee. The authorized representative will agree to make a demand of the FDIC upon our failure to pay interest or principal on any series of the notes when due. As provided in the FDIC’s regulations, a holder will also have the option to elect not to be represented by the authorized representative. Upon our failure to pay interest or principal, the authorized representative and a holder that has elected not to be so represented must follow the FDIC’s required procedures for making a demand under the guarantee. In addition to the procedures described below, the authorized representative will be required when making a demand, to the extent not previously provided in the master agreement, to provide the FDIC with information regarding its authority, including: its financial and organizational capacity to act as representative, its exclusive authority to act on behalf of each noteholder and its fiduciary responsibility to the noteholders when acting as such, as established by the senior indenture, and its authority to make the assignment of each noteholder’s right, title, and interest in the notes to the FDIC. Any demand under the guarantee must be accompanied by a proof of claim, satisfactory in form and content to the FDIC, which includes evidence of the occurrence of a payment default and the claimant’s ownership of the applicable notes. The claimant must provide to the FDIC an assignment, satisfactory in form and content to the FDIC, of the noteholder’s right, title and interest in the notes to the FDIC and the transfer to the FDIC of any claim in any insolvency proceeding against us. The assignment must also grant to the FDIC the right to receive any and all distributions on the note from the proceeds of any bankruptcy. If a holder receives a payment on a note from a bankruptcy, any obligation of the FDIC under the guarantee would be reduced proportionally. Demands must be made by the authorized representative or by a holder that elects not to be represented by the authorized representative within 60 days of the occurrence of the payment default. Upon payment by the FDIC of any amount under the guarantee, the FDIC will be subrogated to the rights of the recipient noteholder against us, including in respect of any insolvency proceeding, to the extent of such payment.

  • Customer Relations A. Actively promote DCP Holding Company in all Marketing, Sales, Public Relations, and Community activity. B. Strategize that the DCP Holding Company product is placed effectively before the public with emphasis on “Agent/Broker” C. Continually monitor the success, quality and effectiveness of DCP Holding Company marketing

  • Evaluation Process ‌ A. The immediate supervisor will meet with an employee at the start of their review period to discuss performance expectations. The employee will receive copies of their performance expectations as well as notification of any modifications made during the review period. Employee work performance will be evaluated during probationary, trial service and transition review periods and at least annually thereafter. Notification will be given to a probationary or trial service employee whose work performance is determined to be unsatisfactory. B. The supervisor will discuss the evaluation with the employee. The employee will have the opportunity to provide feedback on the evaluation. The discussion may include such topics as: 1. Reviewing the employee’s performance; 2. Identifying ways the employee may improve their performance; 3. Updating the employee’s position description, if necessary; 4. Identifying performance goals and expectations for the next appraisal period; and 5. Identifying employee training and development needs. C. The performance evaluation process will include, but not be limited to, a written performance evaluation on forms used by the Employer, the employee’s signature acknowledging receipt of the forms, and any comments by the employee. A copy of the performance evaluation will be provided to the employee at the time of the review. A copy of the final performance evaluation, including any employee or reviewer comments, will be provided to the employee. The original performance evaluation forms, including the employee’s comments, will be maintained in the employee’s personnel file. D. If an employee disagrees with their performance evaluation, the employee has the right to attach a rebuttal. E. The performance evaluation process is subject to the grievance procedure in Article 30. The specific content of a performance evaluation is not subject to the grievance procedure. F. Performance evaluations will not be used to initiate personnel actions such as transfer, promotion, or discipline.

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