Second Level Appeal for Adverse First Level Appeal Decision of a Utilization Review Determination
Second Level Appeal for Adverse First Level Appeal Decision of a Utilization Review Determination Sample Clauses
Related to Second Level Appeal for Adverse First Level Appeal Decision of a Utilization Review Determination
Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:
Additional RO Review Criteria (1) In addition to the requirements in Subparagraph 34A, the RO must:
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.
Adverse Benefit Determination An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.
Peer Review Dental Group, after consultation with the Joint ----------- Operations Committee, shall implement, regularly review, modify as necessary or appropriate and obtain the commitment of Providers to actively participate in peer review procedures for Providers. Dental Group shall assist Manager in the production of periodic reports describing the results of such procedures. Dental Group shall provide Manager with prompt notice of any information that raises a reasonable risk to the health and safety of Group Patients or Beneficiaries. In any event, after consultation with the Joint Operations Committee, Dental Group shall take such action as may be reasonably warranted under the facts and circumstances.
Mid-Term Review The Borrower shall:
Claims Review Methodology a. C laims Review Population. A description of the Population subject to the Quarterly Claims Review.
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.
HHS Single Audit Unit will notify Grantee to complete the Single Audit Determination Form If Grantee fails to complete the form within thirty (30) calendar days after receipt of notice, Grantee maybe subject to sanctions and remedies for non-compliance.
Technical Objections to Grievance No grievance will be defeated or denied by any minor technical objection.
