Provider Dispute Resolution Process Sample Clauses

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, at a minimum: • Informal and formal processes for settlement of Provider Disputes. • Acceptance and usage of this Agreement’s definition of Provider Appeals and Provider Disputes. • Time frames for submission and resolution of Provider Disputes and Provider Appeals. • Processes to provide equitability for all Providers. • Mechanisms and time frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, and the Department. • Establishment of a CHC-MCO Committee to process formal Provider Appeals, which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee members in making decisions. – Documentation of meetings and decisions of the Committee.
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Provider Dispute Resolution Process. 6.4.1 TSS has established a procedure to resolve billing, payment, and other administrative disputes between Providers and TSS arising under this Addendum including a Provider Complaint resolution process implemented by TSS to address, among others, lost or incomplete Claims forms or electronic submissions; TSS’ requests for additional explanation as to services or treatment rendered by a Provider; and inappropriate or unapproved Referrals issued by Providers. This dispute resolution process shall exclude Grievances filed by Providers on behalf of Enrollees pursuant to Section 14.3 of the GHP Program Contract.
Sample 1

Related to Provider Dispute Resolution Process

  • Dispute Resolution Process Any claim, dispute or other matter in question not resolved by the process identified in Paragraph

  • Dispute Resolution Procedure 21.1 All disputes or grievances arising between the Parties shall as far as practical be resolved at the workplace level through consultation. Accordingly the following procedure must be followed:

  • Dispute Resolution Procedures (a) In the event a dispute arises about the interpretation, application, calculation of Loss, or calculation of payments or otherwise with respect to this Single Family Shared-Loss Agreement (“SF Shared-Loss Dispute Item”), then the Receiver and the Assuming Institution shall make every attempt in good faith to resolve such items within sixty (60) days following the receipt of a written description of the SF Shared-Loss Dispute Item, with notification of the possibility of taking the matter to arbitration (the date on which such 60-day period expires, or any extension of such period as the parties hereto may mutually agree to in writing, herein called the “Resolution Deadline Date”). If the Receiver and the Assuming Institution resolve all such items to their mutual satisfaction by the Resolution Deadline Date, then within thirty (30) days following such resolution, any payment due as a result of such resolution shall be made arising from the settlement of the SF Shared-Loss Dispute.

  • Applicable Law; Dispute Resolution i. This Agreement, and all claims, disputes or disagreements arising out of or connected with this Agreement, its validity or any breach thereof, shall be governed by the laws in effect in the State of Texas (excluding conflicts of laws provisions), and to the extent applicable to maritime issues, the maritime laws of the United States (excluding conflict of laws provisions).

  • Dispute Resolution All or any disputes arising out or touching upon or in relation to the terms and conditions of this Agreement, including the interpretation and validity of the terms thereof and the respective rights and obligations of the Parties, shall be settled amicably by mutual discussion, failing which the same shall be settled through the adjudicating officer appointed under the Act.

  • Alternate Dispute Resolution In the event of any issue of controversy under this Agreement, the PARTIES may pursue Alternate Dispute Resolution procedures to voluntarily resolve those issues. These procedures may include, but are not limited to, conciliation, facilitation, mediation, and fact finding.

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