Provider Appeals Sample Clauses

Provider Appeals. 1. The HMO must inform providers in writing (either electronically or hard copy) of the HMO’s decision to pay or deny the original claim. HMOs who use the HIPAA 835 transaction set to notify providers of payment determination must include the below elements in their contract or MOU with providers or in their provider manual, or through written notification for non-contracted providers. Written notification of payment or denial must include the following information: a. A specific explanation of the payment amount or a specific reason for the nonpayment. b. A statement regarding the provider’s rights to appeal to the HMO. c. The name of the person and/or function at the HMO to whom provider appeals should be submitted. d. An explanation of the process the provider should follow when appealing the HMO’s decision to the HMO, which includes the following steps: 1) Include a separate letter or form clearly marked “appeal.” 2) Include the provider’s name, date of service, date of billing, date of payment and/or nonpayment, member’s name and Badger Care Plus and/or Medicaid SSI ID number. 3) Include the reason(s) the claim merits reconsideration. 4) If the provider’s complaint is medical (emergency, medical necessity and/or prior authorization), the HMO must indicate if medical records are required and need to be submitted with the appeal. 5) Address the letter or form to the person and/or function at the HMO that handles provider appeals. 6) Send the appeal within 60 days of the initial denial or payment notice. e. A statement advising the provider of the provider’s right to appeal to the Department if the HMO fails to respond to the appeal within 45 days or if the provider is not satisfied with the HMO’s response to the request for reconsideration. All BadgerCare Plus and Medicaid SSI providers must appeal first to the HMO and then to the Department if they disagree with the HMO’s payment or nonpayment of a claim. Appeals to the Department must be submitted in writing within 60 days of the HMO’s final decision or, in the case of no response, within 60 days from the 45 day timeline allotted the HMO to respond. Providers must use the Department’s form when submitting a provider appeal for State review, and all elements of the form must be completed at the time the form is submitted (i.e. medical records for appeals regarding medical necessity). The form is available at the following website: xxxx://xxx.xxxxxxxxx.xxx/forms/F1/F12022.doc. Appeals to the Department ...
Sample 1
AutoNDA by SimpleDocs
Provider Appeals. 1. The HMO must inform providers in writing (either electronically or hard copy) of the HMO’s decision to pay or deny the original claim. HMOs who use the HIPAA 835 transaction set to notify providers of payment determination must include the below elements in their contract or MOU with providers or in their provider manual, or through written notification for non-contracted providers. Written notification of payment or denial must occur on the date of action when the action is denial of payment and include the following information: a. A specific explanation of the payment amount or a specific reason for the nonpayment. b. A statement regarding the provider’s rights to appeal to the HMO. c. The name of the person and/or function at the HMO to whom provider appeals should be submitted. d. An explanation of the process the provider should follow when appealing the HMO’s decision to the HMO, which includes the following steps: 1) Include a separate letter or form clearly marked “appeal.” 2) Include the provider’s name, date of service, date of billing, date of payment and/or nonpayment, member’s name and Badger Care Plus and/or Medicaid SSI ID number. 3) Include the reason(s) the claim merits reconsideration. 4) If the provider’s complaint is medical (emergency, medical necessity and/or prior authorization), the HMO must indicate if medical records are required and need to be submitted with the appeal. 5) Address the letter or form to the person and/or function at the HMO that handles provider appeals. 6) Send the appeal within 60 days of the initial denial or payment notice. 7) A statement advising the provider of the provider’s right to appeal to the Department if the HMO fails to respond to the appeal within 45 days or if the provider is not satisfied with the HMO’s response to the request for reconsideration. All BadgerCare Plus and Medicaid SSI providers must appeal first to the HMO and then to the Department if they disagree with the HMO’s payment or nonpayment of a claim. Appeals to the Department must be submitted in writing within 60 days of the HMO’s final decision or, in the case of no response, within 60 days from the 45 day timeline allotted the HMO to respond. Providers must use the Department’s form when submitting a provider appeal for State review. All elements of the form must be completed and all of the required documents (i.e. copy of the claim, copy of the payment denial remittance, copy of the appeal letter and response, and medical rec...
Sample 1
Provider Appeals. 2.15.1. Contractor’s Internal Reconsideration Process for Service Providers. 2.15.1.1. The Contractor shall have an internal Reconsideration process in place available to providers who wish to challenge decisions made by DMAS, its contractors or agents, regarding payment or authorization for Medicaid- based services that have been rendered to an Enrollee. This process must assure that appropriate decisions are made as promptly as possible. At the conclusion of the Contractor’s internal reconsideration process, the Contractor shall issue a final decision letter to the provider. The final decision letter issued to the provider must be mailed on the date appearing on the final decision letter. The final decision letter must include a statement that the provider has exhausted its reconsideration rights with the Contractor and include an explanation of Appeal rights to DMAS, as specified by DMAS. 2.15.2. Compliance with DMAS’s Provider Appeal Process. 2.15.2.1. Upon exhaustion of the Contractor’s internal reconsideration process for service providers, an Appeal may be filed by service providers, for denial by the DMAS or its agents or contractors, in whole or part, of payment or authorization for Medicaid-based services already rendered to an Enrollee. The provider’s exhaustion of the Contractor’s internal reconsideration process for providers is a prerequisite to filing for an Appeal to DMAS. Requests for Appeals are considered filed when they are date-stamped into the Appeals Division. 2.15.2.2. The normal business hours of DMAS are from 8:00am to 5:00pm on days that DMAS is open for business. Documents filed after normal business hours on the due date shall be untimely. Full adherence and compliance with all of the timelines and requirements of the DMAS Appeals process contained in the Virginia Administrative Code at 12 VAC 00-00-000 et. seq. shall be required by service providers seeking to avail themselves of the DMAS provider Appeal process. The Appeal process is available to: 2.15.2.2.1. Enrolled providers that have rendered services and have been denied payment in whole or part for Medicaid-based services, 2.15.2.2.2. Providers who have received a notice of program reimbursement or overpayment demand related to Medicaid-based services from DMAS or its contractors, 2.15.2.2.3. Providers who have been denied authorization, in whole or part, for Medicaid-based services already rendered, and 2.15.2.2.4. Providers may not Appeal to DMAS issues of enrollment ...
Sample 1
Provider Appeals. Except for termination due Provider, and all systems, manuals, computer to contract expiration, Member Provider has the software and other materials, but excluding patient right to appeal his/her termination from the Network, charts,shall be and remain the sole property of RHG as follows: or Member Provider respectively (collectively, the "Confidential Information"), RHG and Member IX. 1.3.1 RHG will provide notice to the Member Provider acknowledges that the Confidential Provider at least 90 days before the effective date of Information and all other information regarding a termination by RHG; RHG or Member Provider that is competitively sensitive is the property of RHG or Member IX.1,3.2 Upon receipt of the written notification of Provider and RHG or Member Provider may be termination, a Member Provider may request in damaged if such information was revealed to a third writing a review by the Network's advisory review i party. Accordingly, RHG and Member Provider panel no later than 30 days after receipt of the agrees to keep strictly confidential and to hold in notification; trust all Confidential Information. Upon termination of this Agreement by either party for any reason 1X.
Sample 1
Provider Appeals. Amend the second sentence of the first paragraph to read:
Sample 1
Provider Appeals. The subcontractor agrees to abide by the terms of Section O, Appeals to the MCO and Department for Payment/Denial of Providers Claims, page 136 of this article. The MCO must furnish all providers information regarding the provider appeals process at the time they enter into the contract, and through provider materials posted on the MCO’s website or sent to providers, upon request.
Sample 1
Provider Appeals. A provider may appeal regarding refusal to become a new EYE provider or withdrawal of their status as an existing EYE provider. The process for appealing is outlined below. • The provider should send (in writing) reasons for the appeal within 14 working days of a decision being notified, and include any supporting documentation. • Bath and North East Somerset will send an acknowledgement of receipt of the appeal within 5 working days. • A panel of 3 officers in the Children’s Service, who are independent of the original decision, will review the decision through a review of the supporting documentation and an interview with the provider within a further 10 working days of acknowledging the appeal. • The provider will receive a written decision on the appeal within 4 working days of the appeal decision being made. Should you be unhappy with the appeals process Bath and North East Somerset have a corporate complaints procedure and details can be found at this internet address: - xxxx://xxxx.xxxxxxx.xxx.xx/services/your-council-and- democracy/complaints If you are dissatisfied with your treatment under either the appeals procedure or the corporate complaints procedure, you may make a complaint to the Local Authority Ombudsman after the full appeals procedure with Bath and North East Somerset Council has been exhausted. The address for the Local Authority Ombudsman is: A parent/carer may appeal or complain if they are unable to access their full entitlement or where they may not be receiving their EYE within the terms of the national guidance and/or Local Provider Agreement. Bath and North East Somerset’s Children’s Service procedure for can be found at the following internet address/link xxxx://xxxx.xxxxxxx.xxx.xx/services/your-council-and- democracy/complaints/complaints-about-childrens-services-0 or by calling 01225 477931
Sample 1
AutoNDA by SimpleDocs

Related to Provider Appeals

  • Consider Provider as School Official The Parties agree that Provider is a “school official” under FERPA and has a legitimate educational interest in personally identifiable information from education records received from the LEA pursuant to the DPA. For purposes of the Service Agreement and this DPA, Provider: (1) provides a service or function for which the LEA would otherwise use employees; (2) is under the direct control of the LEA with respect to the use and maintenance of education records; and (3) is subject to the requirements of FERPA governing the use and redisclosure of personally identifiable information from the education records received from the LEA.

  • Legal Appeals a. Nothing contained in these provisions is intended to limit or impair the rights of any vendor or Contractor to seek and pursue remedies of law through the judicial process. Appendix C, Contract Modification Procedure, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. Appendix D, Pricing Schedules, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. The Parties expressly agree that these prices are established as “maximum Not-To-Exceed prices”. The Contractor acknowledges that any mini-bid under this Centralized Contract which includes pricing in excess of the “maximum Not-To-Exceed price” shall be rejected by the Authorized User. Amendments to Appendix D, Pricing Schedules, shall be processed in accordance with Appendix C, Contract Modification Procedure, section 4.8, OGS Centralized Contract Modifications and section 4.23 Price Adjustments for OGS Centralized Contracts. Appendix E, Report of Contract Purchases, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. OGS reserves the right to make unilateral changes to this Report of Contract Purchases document. Appendix F, Project Based Information Technology Consulting Services Processes and Forms, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. OGS reserves the right to change the processes and forms set forth Appendix F in non-material and substantive ways without seeking a contract amendment. Appendix F is comprised of the following attachments: a. Attachment 1- Mini-Bid Template b. Attachment 2- How to Use This Contract c. Attachment 3- Enhancement Request Template d. Attachment 4- No Cost Change Request Template e. Attachment 5- Mini-Bid Participation Interest Template Appendix G, Contractor and OGS Information, attached hereto, is hereby expressly made a part of this Contract as fully as if set forth at length herein. The Parties agree that the elements identified in 4.7.1 below, OGS Designated Contact information, and information regarding Procurement Card acceptance as presented in Appendix G can be updated without the Parties engaging in a formal contract amendment. All other changes must be handled through the Contract Modification Process or a formal contract amendment.

  • Provider Network The Panel of health service Providers with which the Contractor contracts for the provision of covered services to Members and Out-of-network Providers administering services to Members.

  • Extended Health Care Plan ‌ The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable extended health care plan.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE

  • Extended Health Care Benefits The City will provide for all employees by contract through an insurer selected by the City an Extended Health Care Plan which will provide extended health care benefits. The City shall pay one hundred per cent (100%) of the premiums, which will include any premiums payable under The Health Insurance Act, R.S.O. 1990, as amended.

  • Provider Services Charges for the following Services when ordered by a Physician for the treatment of an Injury or Illness.

  • Extended Child Care Leave Upon written notification, no later than four weeks prior to the expiration of the aggregate leave taken pursuant to Clauses 21.1 (Maternity Leave) and 21.2 (Parental Leave), an employee will be granted a further unpaid leave of absence not to exceed one year. An employee wishing continued coverage under any applicable benefit plans will pay the total premium costs while on extended child care leave. An employee on extended child care leave will provide the Employer with at least one month's written notice of return from such leave. Upon return from extended child care leave, an employee will be placed in their former position.

  • Appeals a. Should the filer be dissatisfied with the Formal Dispute determination, a written appeal may be filed with the Chief Procurement Officer, by mail or email, using the following contact information: 00xx Xxxxx, Xxxxxxx Xxxxx Xxxxxx Xxxxx Xxxxx Xxxxxx, XX 00000 Email: xxxxxxxx.xxxxxxxx@xxx.xx.xxx Subject line: Appeal – Attn: Chief Procurement Officer b. Written notice of appeal of a determination must be received at the above address no more than ten (10) business days after the date the decision is received by the filer. The decision of the Director of Procurement Services shall be a final and conclusive agency determination unless appealed to the Chief Procurement Officer within such time period. c. The Chief Procurement Officer shall hear and make a final determination on all appeals or may designate a person or persons to act on his/her behalf. The final determination on the appeal shall be issued within twenty (20) business days of receipt of the appeal. d. An appeal of the decision of the Director of Procurement Services shall not include new facts and information unless requested in writing by the Chief Procurement Officer. e. The decision of the Chief Procurement Officer shall be a final and conclusive agency determination.

  • Administrative Appeals An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!