Protests and Appeals Procedures Sample Clauses
Related to Protests and Appeals Procedures
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:
Claims Procedures Each Party entitled to be indemnified by the other Party (an “Indemnified Party”) pursuant to Section 8.1 or 8.2 hereof shall give notice to the other Party (an “Indemnifying Party”) promptly after such Indemnified Party has actual knowledge of any threatened or asserted claim as to which indemnity may be sought, and shall permit the Indemnifying Party to assume the defense of any such claim or any litigation resulting therefrom; provided:
Review and Appeal (a) Each Party shall establish or maintain judicial, quasi-judicial, or administrative tribunals or procedures for the purpose of the prompt review and, where warranted, correction of final administrative actions regarding matters covered by this Treaty. Such tribunals shall be impartial and independent of the office or authority entrusted with administrative enforcement and shall not have any substantial interest in the outcome of the matter.
Appeals Process A. The Contractor’s appeal process shall, at a minimum:
CLAIM PROCEDURES Claim forms or claim information as to the subject policy can be obtained by contacting Benmark, Inc. (800-544-6079). When the Named Fiduciary has a claim which may be covered under the provisions described in the insurance policy, they should contact the office named above, and they will either complete a claim form and forward it to an authorized representative of the Insurer or advise the named Fiduciary what further requirements are necessary. The Insurer will evaluate and make a decision as to payment. If the claim is payable, a benefit check will be issued in accordance with the terms of this Agreement. In the event that a claim is not eligible under the policy, the Insurer will notify the Named Fiduciary of the denial pursuant to the requirements under the terms of the policy. If the Named Fiduciary is dissatisfied with the denial of the claim and wishes to contest such claim denial, they should contact the office named above and they will assist in making an inquiry to the Insurer. All objections to the Insurer's actions should be in writing and submitted to the office named above for transmittal to the Insurer.
Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.
Grievances and Appeals a. If you have questions about any pediatric dental services received, please first discuss the matter with your Dental Provider. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center. You can also email questions by accessing the “Contact Us” section of the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.
Your Grievance and Appeals Rights If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) ◼ Amount owed to providers: $7,540 ◼ Plan pays $7,490 ◼ Patient pays $50 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance $0 Limits or exclusions $30 Total $50 Managing type 2 diabetes (routine maintenance of a well-controlled condition) ◼ Amount owed to providers: $5,400 ◼ Plan pays $4,760 ◼ Patient pays $640 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $300 Coinsurance $300 Limits or exclusions $40 Total $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?
Claims Procedure An Executive or Beneficiary (“claimant”) who has not received benefits under this Agreement that he or she believes should be distributed shall make a claim for such benefits as follows:
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.
