Plan Administrator Action on Appeal Sample Clauses

Plan Administrator Action on Appeal. The Plan Administrator, within a reasonable time, but no later than 60 days after receipt of the request for review, will decide the appeal. The Plan Administrator may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection with the appeal will be different from and not subordinate to any expert consulted in connection with the initial claim denial. The identity of any medical expert consulted in connection with the appeal will be provided. If the decision on review affirms the initial denial of the claim, a notice will be provided which sets forth: Information sufficient to allow the Participant to identify the claim involved (including the date of service, health care provider, claim amount, and, if applicable, the treatment code and its corresponding meaning); The specific reason for the decision on review, including any denial code and its corresponding meaning;The specific HRA Plan provision(s) on which the decision is based; A statement regarding the right to review, upon request and at no charge, relevant documents and other information. If an internal rule, guideline, protocol, or other similar criterion is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and In lieu of an external appeal right, the Plan is required to accept the external appeals decision made in the appeals process for the Health Plan with respect to the corresponding matter.
Sample 1
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Related to Plan Administrator Action on Appeal

  • Plan Administrator Employees must elect a plan administrator during their initial enrollment in Advantage and may change their plan administrator election only during the annual open enrollment and when permitted under Section 5. Dependents must be enrolled through the same plan administrator as the employee.

  • Appeals Committee ‌ An Appeals Committee is hereby established composed of one member appointed by the Union, one member appointed by the Employer or by the Association, as the case may be, and a Public Member appointed by both these members.

  • Claims Administrator A. The Human Resources Director through his/her designated Claims Administrators shall administer the provision of this policy. The City Physician shall provide the City's Claims Administrators with all available medical information concerning the Employee's injury and/or medical opinions as requested. Medical information and opinions shall be based upon the Employee's medical records and/or physical examination. Questions of Employee eligibility shall be determined by the provisions established under State Statute 49-110, 49-111 and Oklahoma Worker's Compensation Title 85. Prior to any denial of injury leave benefits where lost time actually occurred, the administrator shall notify Union and allow a Union representative the opportunity to review the application pending denial and provide any additional information relating to same as may be necessary. Should the City change designated Claims Administrators Local 176 will be notified in writing.

  • Benefits Committee As per LOA#10, a benefits committee comprised of the employee representatives and the employer representatives, including the Crown, shall convene upon request to address all matters that may arise in the operation of the OSSTF ELHT.

  • Appeals Procedure If Employee appeals to the Administrator, Employee or his authorized representative may submit in writing whatever issues and comments he believes to be pertinent. The Administrator shall reexamine all facts related to the appeal and make a final determination of whether the denial of benefits is justified under the circumstances. The Administrator shall advise Employee in writing of:

  • Union Grievance Committee (a) The Employer shall recognize a Union Grievance Committee which consists of:

  • Grievance Committee The Hospital will recognize a Grievance Committee composed of the Chief Xxxxxxx and not more than (as set out in Local Provisions Appendix) employees selected by the Union who have completed their probationary period. A general representative of the Union may be present at any meeting of the Committee. The purpose of the Committee is to deal with complaints or grievances as set out in this Collective Agreement. The Union shall keep the Hospital notified in writing of the names of the members of the Grievance Committee appointed or selected under this Article as well as the effective date of their respective appointments. A Committee member shall suffer no loss of earnings for time spent during their regular scheduled working hours in attending grievance meetings with the Hospital up to, but not including arbitration. The number of employees on the Grievance Committee shall be determined locally.

  • Benefits Advisory Committee The Board agrees to establish a Benefits Advisory Committee to provide stakeholder input into maintaining quality and affordable benefits. The focus of this committee shall be to:

  • Committee Action (a) All matters to be acted on by the Management Committee shall be brought up for a vote or approval in the form of a motion, which must be seconded. Only one motion may be pending at one time.

  • Joint Benefits Committee In order to achieve benefit cost reductions, or at a minimum, cost containment, the parties agree to establish and aggressively participate in a Joint Benefits Committee. The parties agree that the Joint Benefits Committee shall explore all potential options or changes that could generate cost reductions to the Benefit Plans with the following order of priorities:

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