Common use of Preliminary Determination Clause in Contracts

Preliminary Determination. Upon receipt of a Grievance, we shall first determine the type of Grievance at hand.  If the Grievance seeks review of an Adverse Determination of a pre- or post- Health Care Service, it is an Adverse Determination Grievance and we shall review the Grievance in accordance with our procedures for Adverse Determination Grievances and the requirements of state law.  If the Grievance is not based on an Adverse Determination of a pre- or post- Health Care Service, it is an Administrative Grievance and we shall review the Grievance in accordance with its procedures for Administrative Grievances and the requirements of state laws. Timeframes for Initial Determinations  Expedited decision. We shall make our initial Certification or Adverse Determination decision in accordance with the medical exigencies of the case. We shall make decisions within twenty-four (24) hours of the written or verbal receipt of the request for an expedited decision whenever:  the life or health of a Grievant would be jeopardized,  the Grievant’s ability to regain maximum function would be jeopardized,  the Practitioner/Provider reasonably requests an expedited decision,  in the opinion of the Practitioner/Provider with knowledge of the Grievant’s medical condition, would subject the Grievant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim,  the medical exigencies of the case require an expedited decision or  the Grievant’s claim involves Urgent Care.  Standard decision. We shall make all other initial utilization management decisions within five (5) working days. We may extend the review period for a maximum of ten (10) working days if we:  can demonstrate reasonable cause beyond its control for the delay,  can demonstrate that the delay will not result in increased medical risk to the Grievant, and  provide a written progress report and explanation for the delay to the Grievant and Practitioner/Provider within the original five (5) working day review period. Initial Determinations

Preliminary Determination. Upon receipt of a Grievance, we shall first determine the type of Grievance at hand. PHPGSAHDHPHIX_Off_2016 SERF# PBHP-130007152 - Off  If the Grievance seeks review of an Adverse Determination of a pre- or post- Health Care Service, it is an Adverse Determination Grievance and we shall review the Grievance in accordance with our procedures for Adverse Determination Grievances and the requirements of state law.  If the Grievance is not based on an Adverse Determination of a pre- or post- Health Care Service, it is an Administrative Grievance and we shall review the Grievance in accordance with its our procedures for Administrative Grievances and the requirements of state laws. Timeframes for Initial Determinations  Expedited decision. We shall make our initial Certification or Adverse Determination decision in accordance with the medical exigencies of the case. We shall make decisions within twenty-four (24) hours of the written or verbal receipt of the request for an expedited decision whenever:  the life or health of a Grievant would be jeopardized,  the Grievant’s ability to regain maximum function would be jeopardized,  the Practitioner/Provider reasonably requests an expedited decision,  in the opinion of the Practitioner/Provider with knowledge of the Grievant’s medical condition, would subject the Grievant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim,  the medical exigencies of the case require an expedited decision or  the Grievant’s claim involves Urgent Care.  Standard decision. We shall make all other initial utilization management decisions within five (5) working days. We may extend the review period for a maximum of ten (10) working days if we:  can demonstrate reasonable cause beyond its our control for the delay,  can demonstrate that the delay will not result in increased medical risk to the Grievant, and  provide a written progress report and explanation for the delay to the Grievant and Practitioner/Provider within the original five (5) working day review period. PHPGSAHDHPHIX_Off_2016 SERF# PBHP-130007152 - Off Initial Determinations