Procedure for Pursuing an External Review – Kansas Department of Insurance Sample Clauses

Procedure for Pursuing an External Review – Kansas Department of Insurance. Members may request External Review of Adverse Health Care Decisions through Kansas Department of Insurance: 1. The Insured has the right, to request an External Review of an Adverse Decision Eligible for External Review after an Appeal (where applicable) has been completed or when the Insured has not received a final Adverse Decision within 60 days of seeking such review, unless the delay was requested by the Insured. In the case of a request for an External Review of an Adverse Decision Eligible for External Review involving an Emergency Medical Condition, such request may be made before the Insured has exhausted all the other available review procedures. The Plan will notify the Insured in writing regarding a final Adverse Decision and of the opportunity to request an External Review. 2. Within 4 months of receipt of the notice of a final Adverse Decision, the Insured, the treating physician or health care provider acting on behalf of the Insured with written authorization from the Insured, or a legally authorized designee of the Insured must make a written request for an External Review to the Kansas Insurance Commissioner, at the Kansas Insurance Department, 0000 XX Xxxxxxxxx Xxxx, Xxxxxx, XX 00000, (000) 000-0000 or (000) 000-0000. 3. Within 10 business days of receipt of such request (immediately, when the request for External Review involves an Emergency Medical Condition), the Kansas Insurance Commissioner will notify the Insured and other involved parties as to whether the request for External Review is granted. 4. For those requests that qualify for External Review, the External Review Organization will issue a written decision to the Insured and the Kansas Insurance Commissioner within 30 business days. The External Review Organization will issue its written decision within 72 hours when the request for External Review involves an Emergency Medical Condition. The standard of review shall be whether the health care service denied by the Company was Medically Necessary or in the case of reviews regarding Experimental or Investigational treatment, whether the health care service denied by the Company was covered or excluded from coverage under the terms of this contract. 5. The decision of the External Review Organization may be reviewed directly by the district court at the request of either the Insured, insurer or health insurance plan. The review by the district court shall be de novo. The decision of the External Review Organization shall not ...
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Related to Procedure for Pursuing an External Review – Kansas Department of Insurance

  • PROCUREMENT ETHICS Contractor understands that a person who is interested in any way in the sale of any supplies, services, construction, or insurance to the State of Utah is violating the law if the person gives or offers to give any compensation, gratuity, contribution, loan, reward, or any promise thereof to any person acting as a procurement officer on behalf of the State of Utah, or who in any official capacity participates in the procurement of such supplies, services, construction, or insurance, whether it is given for their own use or for the use or benefit of any other person or organization.

  • Reinsurance Administration A. Within thirty (30) days after the end of each calendar month, the Cedent shall take all reasonable and appropriate steps to furnish the Reinsurer with a seriatim electronic report, as detailed in Schedule C, for each Reinsured Contract, valued as of the last day of that month. On or before September 30, 2001, the Cedent shall provide the initial seriatim electronic report, which shall cover the period from the Effective Date hereof through August 31, 2001; provided, however, that the initial seriatim electronic report may omit Funding Vehicle Values by MorningStar designation. The Cedent shall provide complete seriatim electronic data, as required herein, on or before April 30, 2002. Failure to provide this information as required shall constitute a material breach within the scope of Article XX, Paragraph G. B. Additionally, within thirty (30) days after the end of each calendar month the Cedent shall furnish the Reinsurer with a separate Summary Statement containing the following: 1. Reinsurance Premiums due to the Reinsurer summarized separately for each premium class by GMDB, EPB, and Income Program, as shown in Exhibit II; 2. benefit claim recoverables due to the Cedent in total and, if applicable, broken down by VNAR, SCNAR, and EEMNAR and Income Program; and 3. the month end date for the period covered by the Summary Statement. C. If the net balance is due to the Reinsurer, the Cedent shall remit the amount due with the Summary Statement, but no later than thirty (30) days after the month end date for the period covered by the Summary Statement. If the net balance is due to the Cedent, the Reinsurer shall remit the amount due to the Cedent within ten (10) days after receipt of the Summary Statement. D. The payment of Reinsurance Premiums is a condition precedent to the liability of the Reinsurer under this Agreement. In the event that the Cedent does not pay the Reinsurance Premiums in a timely manner, as defined below, the Reinsurer may exercise the following rights: 1. The Reinsurer shall charge interest if Reinsurance Premiums are not paid within thirty (30) days of the due date, as defined in Paragraph C of this Article. The interest rate charged shall be based on the ninety-(90) day federal Treasury Xxxx, as published in The Wall Street Journal on the first business day in the month following the due date of the Reinsurance Premiums, plus one hundred (100) basis points. The method of calculation shall be simple interest (360-day year). 2. The Reinsurer may terminate this Agreement in the event that Reinsurance Premium payments are more than sixty (60) days past due after the due date, as described in Paragraph C of this Article, by giving sixty (60) day written notice of termination to the Cedent. As of the close of the last day of this sixty-(60) day notice period, the Reinsurer's liability with respect to the ceded liabilities shall terminate. If all Reinsurance Premiums that are the subject of a sixty (60) day termination notice shall have been received by the Reinsurer within the time specified, the termination notice shall be deemed vacated and the Agreement shall remain in effect.

  • Monitoring and Risk Assessment of Securities Depositories Prior to the placement of any assets of the Fund with a non-U.S. Securities Depository, the Custodian: (a) shall provide to the Fund or its authorized representative an assessment of the custody risks associated with maintaining assets within such Securities Depository; and (b) shall have established a system to monitor the custody risks associated with maintaining assets with such Securities Depository on a continuing basis and to promptly notify the Fund or its Investment Adviser of any material changes in such risk. In performing its duties under this subsection, the Custodian shall use reasonable care and may rely on such reasonable sources of information as may be available including but not limited to: (i) published ratings; (ii) information supplied by a Subcustodian that is a participant in such Securities Depository; (iii) industry surveys or publications; (iv) information supplied by the depository itself, by its auditors (internal or external) or by the relevant Foreign Financial Regulatory Authority. It is acknowledged that information procured through some or all of these sources may not be independently verifiable by the Custodian and that direct access to Securities Depositories is limited under most circumstances. Accordingly, the Custodian shall not be responsible for errors or omissions in its duties hereunder provided that it has performed its monitoring and assessment duties with reasonable care. The risk assessment shall be provided to the Fund or its Investment Advisor by such means as the Custodian shall reasonably establish. Advices of material change in such assessment may be provided by the Custodian in the manner established as customary between the Fund and the Custodian for transmission of material market information.

  • COUNTY’S QUALITY ASSURANCE PLAN The County or its agent will evaluate the Contractor’s performance under this Contract on not less than an annual basis. Such evaluation will include assessing the Contractor’s compliance with all Contract terms and conditions and performance standards. Contractor deficiencies which the County determines are severe or continuing and that may place performance of the Contract in jeopardy if not corrected will be reported to the Board of Supervisors. The report will include improvement/corrective action measures taken by the County and the Contractor. If improvement does not occur consistent with the corrective action measures, the County may terminate this Contract or impose other penalties as specified in this Contract.

  • PROFESSIONAL RESPONSIBILITY (APPLIES TO RNS ONLY 19.01 The parties agree that resident care is enhanced if concerns relating to professional practice and workload are resolved in a timely and effective manner, as set out below; In the event that the Home assigns a number of residents or a workload to an individual employee or group of employees, such that she or they have cause to believe that she or they are being asked to perform more work than is consistent with proper resident care, she or they shall: i) At the time the workload issue occurs, discuss the issue within the Home to develop strategies to meet resident care needs using current resources. If necessary, using established lines of communication, seek immediate assistance from an individual(s) identified by the Home who has responsibility for timely resolution of workload issues. ii) Failing resolution at the time of occurrence of the workload issue, complain in writing to the Union-Management Committee within twenty (20) calendar days of the alleged improper assignment. The chairperson of the Union-Management Committee shall convene a meeting of the Union-Management Committee within twenty (20) calendar days of the filing of the complaint. The Union-Management Committee shall hear and attempt to resolve the complaint to the satisfaction of both parties. The Employer will provide a written response to the Union, with a copy to the ONA representation within ten (10) calendar days. iii) Prior to the complaint being forwarded to the Independent Assessment Committee, the Union may forward a written report outlining the complaint and recommendations to the Director of Resident Care and/or the Administrator. iv) At any time during this process, the parties may agree to the use of a mediator to assist in the resolution of the Professional Practice issues. v) Any settlement arrived at under 19.01 (a) i) – iii) shall be signed by the parties. vi) Failing resolution of the complaint within twenty (20) calendar days of the meeting of the Union-Management Committee, the complaint shall be forwarded to an independent Assessment Committee composed of three (3) registered nurses; one chosen by the Ontario Nurses' Association, one chosen by the Home and one chosen from a panel of independent registered nurses who are well respected within the profession. The member of the Committee chosen from the panel of independent registered nurses shall act as Chairperson. vii) The Independent Assessment Committee shall set a date to conduct a hearing into the complaint, within twenty (20) calendar days of its appointment, and shall be empowered to investigate as is necessary to properly assess the merits of the complaint. The Independent Assessment Committee shall report its findings, in writing, to the parties within twenty (20) calendar days following completion of its hearing. (b) i) The list of Independent Assessment Committee Chairpersons is attached as Appendix “B”. The members of the panel shall sit in rotation as agreed by the parties. If a panel member is unable to sit within the time limit stipulated, the panel member next scheduled to sit will be appointed by the parties.

  • Data Protection Impact Assessment If, pursuant to Data Protection Law, Customer (or its Controllers) are required to perform a data protection impact assessment or prior consultation with a regulator, at Customer’s request, SAP will provide such documents as are generally available for the Cloud Service (for example, this DPA, the Agreement, audit reports or certifications). Any additional assistance shall be mutually agreed between the Parties.

  • Information for Regulatory Compliance Each of the Company and the Depositary shall provide to the other, as promptly as practicable, information from its records or otherwise available to it that is reasonably requested by the other to permit the other to comply with applicable law or requirements of governmental or regulatory authorities.

  • WORKPLACE SAFETY AND INSURANCE BOARD Clause 14.01 (a) When a probationary or regular employee, through employment with the Employer, suffers an injury or disability, or a recurrence of an injury or disability, the Employer shall pay the employee an amount, when combined with the Workplace Safety and Insurance Board payment, equals the employee’s regular wage less deductions required by law, for a period of nine (9) months from the first day of absence. (b) Pending receipt of payment from the Workplace Safety and Insurance Board, an employee shall receive advances up to the amount of the employee’s regular wage rate, less income tax deductions and shall continue to receive their regular wage rate during the period of absence up to nine (9) months provided that: i. the employee will make reasonable effort to ensure prompt completion of necessary forms and information required to receive approval of Workplace Safety and Insurance Board payment; ii. the employee will be expected to fully participate in alternate work, if recommended, by the employee’s medical doctor; iii. the employee’s claim has not been disallowed by the Workplace Safety and Insurance Board, and; iv. the employee agrees in writing, to sign over to the Employer the Workplace Safety and Insurance Board payments. (a) The Employer shall continue to pay for a period of time not to exceed thirty (30) months from the first day of an injury or disability, the premium cost for health and insurance benefits as covered by Clauses 16.03 and 16.04. (b) Should an employee return to work from an injury or disability for a period of six (6) continuous months and subsequently suffers a recurrence of an injury or disability, then the provisions of Clauses 14.02(a) and 14.03(a) shall apply. (c) Notwithstanding Clause 14.02(b), if an employee having ceased to be disabled returns to work and again becomes disabled from the same or related cause within six (6) months, it would be considered as one (1) continuous period of disability as per Clauses 14.02(a) and 14.03(a). (a) For a period of up to thirty (30) months from the first day of injury or disability, the employee shall be eligible to return to their same position classification if capable of performing the required work. If unable to perform the required work, the employee shall be given all reasonable consideration for any available job for which the employee is able and qualified to perform. (b) Notwithstanding Part (a), if any employee’s position is declared redundant while on WSIB leave, the employee upon their return shall exercise normal bumping procedures as per Article 8.

  • PROFESSIONAL GRIEVANCE PROCEDURE A. Any claim by the Association or a teacher that there has been a violation, misinterpretation, or misapplication of the terms of the Agreement or violation of any established policy shall be a grievance and shall be resolved through the procedure set forth herein. B. In the event that a teacher, or the Association believes there is a basis for a grievance, the teacher or representative of the Association within thirty (30) working days of the time the teacher knew of the circumstances giving rise to the grievance, shall first discuss the alleged grievance with the building principal either personally or accompanied by the Association Representative. The grievance process may begin at the Superintendent’s level when the building principal is not involved with an alleged incident. C. If, as a result of the informal discussion with the building principal, a grievance still exists, the teacher or representative of the Association may, within ten (10) working days, invoke the formal grievance procedure through the Association on the grievance report form, signed by the grievant and a representative of the Association. Said form shall be available from the Association Representative in each building. A copy of the grievance form shall be delivered to the building principal, it may be filed with the Superintendent or a representative designated by him. D. Within five (5) working days of receipt of the grievance the principal shall meet with the Association in an effort to resolve the grievance. The principal shall indicate his/her disposition of the grievance in writing within five (5) working days of such meeting and shall furnish a copy thereof to the Association. If the Association desires to proceed to the next step, it shall do so within fifteen (15) calendar days of the principal’s disposition. E. If the Association is not satisfied with the disposition of the grievance, or if no disposition has been made within five (5) working days of such meeting (or ten [10] working days from the date of filing, whichever shall be later) the grievance shall be transmitted to the Superintendent. Within seven (7) working days the Superintendent or his/her designee, shall meet with the Association concerning the grievance and shall indicate his/her disposition of the grievance in writing within five (5) working days of such meeting, and shall furnish a copy thereof to the Association. F. If the Association is not satisfied with the disposition of the superintendent, or if no disposition has been received within five (5) working days of such meeting the Association may proceed to a Board Level Hearing. This grievance hearing shall be heard in closed session, so long as it does not violate the open meetings act. If the grievance is not settled at the preceding step, it may be submitted to binding arbitration. Within fifteen (15) working days of the receipt of the Superintendent’s answer, the party choosing to arbitrate must give written notice to the other party, setting forth specifically the nature of the dispute to be arbitrated. The charging party shall file a Demand for Arbitration with the American Arbitration Association within fifteen (15) days from the notification date that arbitration will be pursued. The arbitrator shall be selected by the American Arbitration Association in accordance with its rules, which shall likewise govern the arbitration proceedings. G. The arbitrator shall have no power to rule on any of the following: 1. The termination of services of or failure to re-employ any probationary teacher. 2. Any claim or complaint for which there is another remedial procedure or forum established by law or by regulation having the force of law, including any matter subject to the procedures specified in the Teacher’s Tenure Act (Act IV Public Acts, Extra Session of 1937 of Michigan, as amended). 3. Any matter involving the content of a teacher evaluation. H. The Board and the Association shall not be permitted to assert in such arbitration proceedings any ground or to rely on any evidence not previously disclosed to the other party. The arbitrator shall have no power to alter, add to, or subtract from the terms of this Agreement. Both parties agree to be bound by the decision of the arbitrator and agree that judgment thereon may be entered in any court of competent jurisdiction. I. The fees and expense of the arbitrator shall be shared equally by both parties. J. The time limits provided in this Article shall be strictly observed but may be extended by written agreement of the parties. In the event a grievance is filed after May 15 of any year and strict adherence to the time limits may result in hardship to any party, the Board shall use its best efforts to process such grievance prior to the end of the school term or as soon thereafter as possible.

  • Grievance Commissioner System This is to confirm the discussion of the parties during collective bargaining that they are committed to encouraging early discussion and resolution of labour relations issues at the local level and seek to resolve grievances in a timely and cost efficient manner. To that end, this is to confirm that pursuant to Article 8, the parties agree that the Employer and Union at individual nursing homes may agree to utilize the following process in order to resolve a particular grievance through the utilization of a joint mediation-arbitration procedure:

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