Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
TIMELINESS OF BILLING SUBMISSION The parties agree that timeliness of billing is of the essence to this Contract and recognize that the City is on a fiscal year. All xxxxxxxx for dates of service prior to July 1 must be submitted to the City no later that the first Friday in August of the same year.
How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.
Review and Selection Process The Project Narratives of SAMHSA applications are peer-reviewed according to the evaluation criteria listed above. Decisions to fund a grant are based on the strengths and weaknesses of the application as identified by peer reviewers. The results of the peer review are advisory in nature. The program office and approving official make the final determination for funding based on the following: • Individual awards over $250,000 are approved by the Center for Mental Health Services National Advisory Council; • Availability of funds; • Equitable distribution of awards in terms of geography (including urban, rural, and remote settings) and balance among populations of focus and program size; • Submission of any required documentation that must be submitted prior to making an award; and • SAMHSA is required to review and consider any information about your organization that is in the Federal Award Performance and Integrity Information System (FAPIIS). In accordance with 45 CFR 75.212, SAMHSA reserves the right not to make an award to an entity if that entity does not meet the minimum qualification standards as described in section 75.205(a)(2). If SAMHSA chooses not to award a fundable application in accordance with 45 CFR 75.205(a)(2), SAMHSA must report that determination to the designated integrity and performance system accessible through the System for Award Management (XXX) [currently, FAPIIS]. You may review and comment on any information about your organization that a federal awarding agency previously entered. XXXXXX will consider your comments, in addition to other information in FAPIIS in making a judgment about your organization’s integrity, business ethics, and record of performance under federal awards when completing the review of risk posed as described in 45 CFR 75.205 HHS Awarding Agency Review of Risk by Applicants.
Review Protocol A narrative description of how the Claims Review was conducted and what was evaluated.
Recertification Upon expiration of the time period which the health care provider originally estimated that the employee needed for his/her own serious health condition, the City may require the employee to obtain recertification if additional leave is requested.
Claims Review Methodology a. C laims Review Population. A description of the Population subject to the Quarterly Claims Review.
INSTRUCTIONS FOR COMPLETING FORM A AND B Form A and Form B should be completed for Contracts for consulting services in accordance with Section XI.18.C of the Office of the State Comptroller’s Guide to Financial Operations (xxxx://xxx.xxx.xxxxx.xx.xx/agencies/guide/MyWebHelp/), “Consultant Disclosure Legislation,” and the following:
Project Reports; Completion Report 1. The Recipient shall monitor and evaluate the progress of the Project and prepare Project Reports in accordance with the provisions of Section 2.06 of the Standard Conditions and on the basis of indicators agreed with the World Bank. Each Project Report shall cover the period of one (1) calendar semester, and shall be furnished to the World Bank not later than one (1) month after the end of the period covered by such report.
Review of Submittals A/E and ODR review is only for conformance with the design concept and the information provided in the Contract Documents. Responses to submittals will be in writing. The approval of a separate item does not indicate approval of an assembly in which the item functions. The approval of a submittal does not relieve the Contractor of responsibility for any deviation from the requirements of the Contract unless the Contractor informs the A/E and ODR of such deviation in a clear, conspicuous, and written manner on the submittal transmittal and at the time of submission, and obtains the A/E’s and Owner’s written specific approval of the particular deviation.
