Member Grievance Procedures Sample Clauses

Member Grievance Procedures. Except for non-payment of the membership fee or loss of eligibility, SkyMed will give at least forty-five (45) days written notice of any cancellation, termination or non-renewal of this Agreement including the reason for such action. SkyMed may cancel or terminate the coverage of a Member for the following reasons: • Fraud or material misrepresentation in applying for or presenting any claim for benefits • Misuse of the documents provided as evidence of services; • Non-payment of membership fee; and • A dependent reaching the limiting age for eligibility. However, if prior to reaching the limiting age a dependent child becomes handicapped, coverage will continue for a handicapped child who is handicapped and incapable of self-sustaining employment by reason of mental or physical handicap and substantially dependent for support and maintenance on the Member. Except for a dependent reaching the limiting age for eligibility, a Member shall not have conversion rights if the membership was terminated for any of the reasons stipulated in this provision. In the event of death of the Member, SkyMed will extend the Membership to the surviving spouse/companion to a value of the remaining and unused term of the deceased’s Membership, and at expiration, renewal rights will be available. In the event of death of all adult Members in the Membership, the remaining and unused term of the deceased’s Membership may be transferred to surviving family members as designated by the deceased’s notarized instructions. Termination of this agreement by SkyMed shall be without prejudice to any continuous loss which commenced while the agreement was in force providing that such Member’s right to such services accrued in connection with a serious or critical Injury or Illness which occurred prior to such termination by SkyMed. The benefit extension shall be for services that commenced prior to termination have been completed or a period of ninety (90) days from the termination date, whichever is the lesser period of time. SkyMed reserves the right to obtain any past or current medical records and insurance information of the Member. In order to mitigate any losses, the member agrees that SkyMed shall have the right to recover any benefits paid hereunder. Member agrees to cooperate, to protect SkyMed’s rights, and to assist SkyMed in mitigating these rights. The following procedures apply in the event that any Member has a grievance of any nature in connection with SkyMed Internationa...
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Member Grievance Procedures. PROVIDER shall participate in and be bound by the applicable Benefits Program, Member's Certificate, and the applicable Member grievance procedure, as set forth in the Operations Manual.
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Member Grievance Procedures. Molina shall abide by Foundation's Member Grievance Procedures which are attached hereto and incorporated herein as Addendum X. Xxxxxx shall abide by, and implement upon request, all Foundation, DOC and DHS determinations on Molina Member appeals and grievances. Molina understands and further agrees as follows.
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Member Grievance Procedures. Molina shall abide by Maxicare's Member Grievance Procedures as may be amended from time to time, with approval of DOC and DHS which are briefly summarized in the Evidence of Coverage attached as Addendum B and a more complete copy of which will be separately provided, along with any updates thereto, by Maxicare.. Molina shall abide by, and implement upon request, all Maxicare, DOC and DHS determinations on Molina Member appeals and grievances. To the extent that Maxicare delegates any member relations functions to Molina, Maxicare shall oversee the performance of those functions. Molina shall assure that Maxicare is notified within one (1) day of any Molina Member complaint or grievance received by Molina or any Molina Participating Provider. A copy of Maxicare's current Member Grievance Procedure is attached hereto as Addendum J and is incorporated by reference herein. Notwithstanding the terms of Section 11.02, Addendum J may be amended by Maxicare, by providing Molina with written notice of the change, provided the change has been approved by DHS and DOC.
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Member Grievance Procedures. RPO shall abide by the determination of the applicable Payor's Member Grievance Procedure, including but not limited to grievance procedures for resolving disputes regarding the necessity for continued treatment, as described in the Texas HealthSpring Member Grievance Procedures. RPO shall cause each RPO Provider to post, in the office, a notice to Member(s) on the process for resolving complaints. The notice must include the Texas Department of Insurance's toll free telephone number. Texas HealthSpring will not engage in any retaliatory action, including refusal to renew coverage or cancellation of coverage, against an employer or Member because the employer, Member or person acting on behalf of the employer or Member has filed a complaint against or appealed a decision of Texas HealthSpring. Texas HealthSpring will not engage in any retaliatory action, including termination or refusal to renew a contract, against a physician or provider, because the physician or provider has, on behalf of a Member, filed a complaint against, or appealed a decision of Texas HealthSpring. In the event the Member or Medicare+Choice Member submits an appeal to Texas HealthSpring, Texas HealthSpring shall provide RPO with the Member or Medicare+Choice Member appeal. RPO shall review the Member or Medicare+Choice Member appeal, performing any necessary research or investigation and providing a determination and response to Texas HealthSpring within three (3) days of receipt from Texas HealthSpring, for a Member appeal, or as required by the Texas Department of Insurance, and within twenty-four (24) hours of receipt from Texas HealthSpring for a Medicare+Choice Member, or as required by the then current CMS guidelines.
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Related to Member Grievance Procedures

  • GRIEVANCE PROCEDURE 7.01 For purposes of this Agreement, a grievance is defined as a difference arising between the parties relating to the interpretation, application, administration or alleged violation of the Agreement including any question as to whether a matter is arbitrable.

  • DISCIPLINARY AND GRIEVANCE PROCEDURES 16.1 The Employee is subject to the Company's disciplinary and grievance procedures, copies of which are available from the Group HR Manager. These procedures do not form part of the Employee's contract of employment.

  • Compliance Procedures The Adviser will, in accordance with Rule 206(4)-7 of the Advisers Act, adopt and implement written policies and procedures reasonably designed to prevent violations of the Advisers Act and will provide the Trust with copies of such written policies and procedures upon request.

  • Advance Procedures A request for advance made by telephone must be promptly confirmed in writing by such method as the Bank may require. The Borrower authorizes the Bank to accept telephonic requests for advances, and the Bank shall be entitled to rely upon the authority of any person providing such instructions. The Borrower hereby indemnifies and holds the Bank harmless from and against any and all damages, losses, liabilities, costs and expenses (including reasonable attorneys' fees and expenses) which may arise or be created by the acceptance of such telephone requests or making such advances. The Bank will enter on its books and records, which entry when made will be presumed correct, the date and amount of each advance, the interest rate and interest period applicable thereto, as well as the date and amount of each payment.

  • New Procedures New procedures as to who shall provide certain of these services in Section 1 may be established in writing from time to time by agreement between the Fund and the Transfer Agent. The Transfer Agent may at times perform only a portion of these services and the Fund or its agent may perform these services on the Fund's behalf;

  • Sale Procedures In connection with its obligations under this Article II, the Partnership will, as expeditiously as possible:

  • Review Procedures The Parties agree to jointly conduct a review, sampling transactions of the incidents managed under this Agreement. Findings that are inconsistent with the normal or accepted way of doing business will be reconciled on a case by case basis. Any decision to further examine records will be considered on a case by case basis and appropriate follow up action agreed upon by all agencies involved. Payment for Protection Services (use if appropriate) Geographic, Statewide or Sub-Geographic (local) operating plans and procurement documents or agreement will establish billing procedures for Fee Basis Protection Services.

  • Notice Procedures In connection with each Auction, the Borrower will provide notification to the Auction Manager (for distribution to the Term Lenders of the applicable Class of Term Loans (each, an “Auction Notice”). Each Auction Notice shall contain (i) the maximum principal amount (calculated on the face amount thereof) of Term Loans of each applicable Class that the Borrower offers to purchase in such Auction (the “Auction Amount”) which shall be no less than $25,000,000 (unless another amount is agreed to by the Administrative Agent); (ii) the range of discounts to par (the “Discount Range”) expressed as a range of prices per $1,000 (in increments of $5), at which the Borrower would be willing to purchase Term Loans of each applicable Class in such Auction; and (iii) the date on which such Auction will conclude, on which date Return Bids (as defined below) will be due by 1:00 p.m. (New York time) (as such date and time may be extended by the Auction Manager, such time the “Expiration Time”). Such Expiration Time may be extended for a period not exceeding three (3) Business Days upon notice by the Borrower to the Auction Manager received not less than 24 hours before the original Expiration Time; provided that only one extension per offer shall be permitted. An Auction shall be regarded as a “failed auction” in the event that either (x) the Borrower withdraws such Auction in accordance with the terms hereof or (y) the Expiration Time occurs with no Qualifying Bids (as defined below) having been received. In the event of a failed auction, the Borrower shall not be permitted to deliver a new Auction Notice prior to the date occurring three (3) Business Days after such withdrawal or Expiration Time, as the case may be. Notwithstanding anything to the contrary contained herein, the Borrower shall not initiate any Auction by delivering an Auction Notice to the Auction Manager until after the conclusion (whether successful or failed) of the previous Auction (if any), whether such conclusion occurs by withdrawal of such previous Auction or the occurrence of the Expiration Time of such previous Auction.

  • Reply Procedures In connection with any Auction, each Lender holding the relevant Term Loans subject to such Auction may, in its sole discretion, participate in such Auction and may provide the Auction Agent with a notice of participation (the “Return Bid”) which shall be in a form reasonably acceptable to the Auction Agent, and shall specify (i) a discount to par (that must be expressed as a price at which it is willing to sell all or any portion of such Term Loans) (the “Reply Price”), which (when expressed as a percentage of the par principal amount of such Term Loans) must be within the Discount Range and (ii) a principal amount of such Term Loans, which must be in whole increments of $1,000,000 (or, in any case, such lesser amount of such Term Loans of such Lender then outstanding or which is otherwise reasonably acceptable to the Auction Agent) (the “Reply Amount”). Lenders may only submit one Return Bid per Auction, but each Return Bid may contain up to three bids only one of which may result in a Qualifying Bid. In addition to the Return Bid, the participating Lender must execute and deliver, to be held in escrow by the Auction Agent, an Assignment and Assumption with the dollar amount of the Term Loans to be assigned to be left in blank, which amount shall be completed by the Auction Agent in accordance with the final determination of such Lender’s Qualifying Bid pursuant to clause (c) below. Any Lender whose Return Bid is not received by the Auction Agent by the Auction Response Date shall be deemed to have declined to participate in the relevant Auction with respect to all of its Term Loans.

  • Issuance Procedures By delivering to the Administrative Agent an Issuance Request on or before 12:00 noon, New York City time, on a Business Day, the Borrower may, from time to time irrevocably request, on not less than three nor more than ten Business Days' notice (or such shorter or longer notice as may be acceptable to the Issuer), in the case of an initial issuance of a Letter of Credit, and not less than three nor more than ten Business Days' notice (unless a shorter or longer notice period is acceptable to the Issuer) prior to the then existing Stated Expiry Date of a Letter of Credit, in the case of a request for the extension of the Stated Expiry Date of a Letter of Credit, that the Issuer issue, or extend the Stated Expiry Date of, as the case may be, an irrevocable Letter of Credit on behalf of the Borrower (whether the account party on such Letter of Credit is the Borrower or a Subsidiary of the Borrower) in such form as may be requested by the Borrower and approved by the Issuer, for the purposes described in Section 7.1.9; provided, however, that no extension of the Stated Expiry Date of an outstanding Letter of Credit may provide for a Stated Expiry Date subsequent to the earlier of (i) the Revolving Loan Commitment Termination Date and (ii) one year from the date of such extension. Notwithstanding anything to the contrary contained herein or in any separate application for any Letter of Credit, the Borrower hereby acknowledges and agrees that it shall be obligated to reimburse the Issuer upon each Disbursement paid under a Letter of Credit, and it shall be deemed to be the obligor for purposes of each such Letter of Credit issued hereunder (whether the account party on such Letter of Credit is the Borrower or a Subsidiary of the Borrower). Upon receipt of an Issuance Request, the Administrative Agent shall promptly notify the Issuer and each Lender thereof. Each Letter of Credit shall by its terms be stated to expire on a date (its "Stated Expiry Date") no later than the earlier to occur of (i) the Revolving Loan Commitment Termination Date or (ii) one year from the date of its issuance. The Issuer will make available to the beneficiary thereof the original of each Letter of Credit which it issues hereunder.

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