How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.
Conclusion and Recommendations D. Evaluations for Offenders without a sex offense conviction shall answer the following additional referral questions in the evaluations:
PURPOSE/JUSTIFICATION OF RECOMMENDED ACTION The purpose of the Agreement is to provide the City with the services of one senior criminalist from the Department to perform DNA testing, analysis, and forensic-related consulting as requested by the City, effective upon execution by the Board through June 30, 2015. This Agreement will result in the creation of an additional senior criminalist position. The senior criminalist will be assigned solely to the Santa Xxxxxx Police Department (SMPD).
HHS Single Audit Unit will notify Grantee to complete the Single Audit Determination Form If Grantee fails to complete the form within thirty (30) calendar days after receipt of notice, Grantee maybe subject to sanctions and remedies for non-compliance.
Proposing Integration Activities in the Planning Submission No integration activity described in section 6.3 may be proposed in a CAPS unless the LHIN has consented, in writing, to its inclusion pursuant to the process set out in section 6.3(b).
Office of Inspector General Investigative Findings Expert Review In accordance with Senate Bill 799, Acts 2021, 87th Leg., R.S., if Texas Government Code, Section 531.102(m-1)(2) is applicable to this Contract, Contractor affirms that it possesses the necessary occupational licenses and experience.
Conclusions and Recommendations This is a technically-sound, innovative program to address the health needs of an underserved region of a country, as well as the health needs of an underserved population: newborns. The BCC strategy is in progress and its quality is excellent: print and audio materials have been developed following proper materials development techniques. The laminated picture cards have been praised by all and the main complaint is that not everyone involved in training others has a full set. The trainings on IMNCI and MAMAN, as well as the educational sessions related to IMNCI topics, were well received by all of those who have attended: from health personnel to CHWs to expecting/new mothers. They are described as dynamic, interactive, participatory and interesting, both due to the topics covered, and the techniques used (with special mention to the role plays). Many people have complimented the way the project team has interacted with local authorities, community members, and each other. This favorable review has led to a feeling of ownership among those involved/participating, which will be important to tap into as plans to make this project sustainable are developed. At the policy level, the (former) Project Director has been working closely with colleagues, on bringing the topic of IMCI with a neonatal focus to the national health agenda, with success. Newborn health is now a national health priority, and the Healthy Babies project can be used as a trial of the implementation of the IMNCI in a rainforest site: results from this project will help guide national level strategies with regards to the IMNCI implementation at a national level. Where the project is lacking has been in its scope of work: due mostly to funding issues, as well as various other contextual factors described in that section in detail, the project has only done a small number of the proposed trainings and only developed some of the materials. The good news is that the training materials and capacity is in place, and the materials are drafted and validated and ready to be printed, so the project is in a great position to implement its activities fully with the complete budget they received for Year Three. Moreover, policy work has been focused on the national level. The new Project Director will be based 50% of the time in Pucallpa, which will be key in full involvement in the work towards development of regional health policies that focus on maternal and newborn health improvements. In addition, as the project enters its last two years, it will be crucial to start working strongly towards its sustainability. It is clear that this work must be done in collaboration with the local municipalities. So again, the presence of a Project Director part- time in Pucallpa will be key for this collaborative work and the discussions that need to take place. One issue that will need to be considered during final evaluation, though, is whether the project, hampered by funding restraints in the initiation of this project’s activities, will be able to attain a change in indicators associated to behavior change, such as seeking health care, since activities to changes these behaviors are really only going to fully start in the third year of this project, and this may not be sufficient time to observe significant changes. With regards to specific recommendations, these can be summarized as: Material Printing and Distribution: With the full budget for Year Three, there should be no stopping of the printing and distributing of health materials. Each CHW should have a full set of the laminated picture cards for their educational work. Posters have been validated; now they need to be printed and distributed. Training: The number of sites that have benefitted from the trainings is limited. The syllabi and materials for the trainings and educational sessions have been used and are well-liked. These trainings now need to be conducted in all sites, and refresher workshops need to be scheduled regularly, again, in all sites. CHW Census and Work: One key activity that seems to have inspired more community involvement, especially on behalf of the CHWs, was the implementation of a community census done by the CHWs themselves by dividing the community into sectors and assigning a sector to each worker. This activity has been done in some communities, and has been highly appreciated by all stakeholders. It is recommended that a census with CHWs be conducted in the remaining project sites. In addition, CHWs play a key role in the sustainability of this project, as resources that will remain in their community long after the project has ended. It will be key to train all CHWs, and initiate supervision of all CHWs so that they can start their work and obtain feedback on it in the next two years. Policy Issues and Sustainability: Continue the work at the national level, but start working towards developing regional policies for maternal/neonatal health improvements. The regional level work must also contain a strong emphasis on the sustainability of the project. Moreover, municipalities have a health budget, but may not have all the technical expertise with regards to how to prioritize health expenditures, so regional policy development must be linked with close work and collaboration with municipalities. Finally, related to sustainability and scaling up, with the results of this MTE, the project is in a good position to approach private institutions and corporations for donations towards the project and this population. Crucial to achieving sustainability of the project is the level of community involvement that can be managed in the next two years. It is key for the project team to form community committees and hold meetings and orientation sessions with them and with community leaders. These activities are programmed for the next two years. It is recommended that they be fully supported financially to complete these tasks in all of the key municipalities, given that successfully involving the community is key to long-term sustainability. Updated Workplan: There are various proposed activities, specifically the implementation of the HLBSS training, the development of emergency transportation plans, and the construction of a maternity waiting home, that need to be thoroughly reassessed by the project management. Based on a meeting with the project management team to present the results of this MTE, it is clear that all involved are aware of the issues associated with each of these three activities, and there is no clear decision with regards to how to proceed. The team must decide amongst themselves what the best strategies would be, and update the workplan accordingly. Moreover, there are various activities that they have been involved in, such as policy level work at the national level, which is only minimally described, if at all, in the workplan. It would be strategic for the Healthy Babies team to include these other activities which are focused on improving maternal and neonatal health within their workplan and discuss ways to evaluate how effective these activities were in obtaining their goal. Training/Strengthening Opportunities for Grantee and Partner Organizations: If the Project Management team decides to move forward with HLBSS, and this should be decided soon, then both INMED and XXXXXX expressed interest in technical assistance associated with implementing the HLBSS training, which was not attained partly due to the costs of bringing the HLBSS trainers to Peru. However, the teams recognize this may not be the best time to push the Peruvian MOH towards a decision on supporting HLBSS due to the political discussions regarding institutional vs. home births. Moreover, INMED had stated interest in strengthening its monitoring and evaluation skills, and the former Project Director in obtaining more training on child survival. I recommend that all partners discuss how their training interests have evolved, if at all, how to meet these training needs in the next two years, within the scope of the existing two years of funding. Funding: With two years left to go, and much to be accomplished, but a good track record for the initial portion of their work, this project should get full funding to finalize its workplan. Moreover, the project management team must continue to meet annually to discuss how to prioritize expenditures on specific activities to ensure that all partners involved have a clear picture of how the funding for the entire year will flow, and on what particular activities. A large portion of the funding must be allocated to the operationalizing of field activities, such as trainings and policy meetings, which are a lot more expensive than originally expected due to distances, access and expenses associated with these.
