Standard Appeals Sample Clauses

Standard Appeals. A standard appeal is a verbal or written request to review an adverse determination. The review is conducted by a peer reviewer who was not involved in the original adverse determination nor is the subordinate of the peer making the original adverse determination. A standard appeal applies to non-urgent, pre-service or retrospective pre-claim requests. Local specialty providers and independent review organizations are review consultants who may be utilized in the appeal process. Standard appeals may be requested within one hundred eighty (180) days from the date of notice of the original adverse determination letter. A final determination following the standard appeal will be made within thirty (30) days of receipt of the request. To initiate a standard appeal: (a) Call the Customer Service number listed on the back of the Member's ID card or submit in writing as instructed on the original adverse determination letter. (b) Have all related clinical information available for the denied services outlined in a letter/statement indicating the issue and resolution being sought which includes:  Name of the requestor  Phone number of the requestor  Member name  Member ID number  Member reference number if known  Date of serviceName of facility where services are being rendered, if applicable  Name of ordering/attending physician  Any new clinical/medical record information Group acknowledges that it will have only one (1) standard appeal opportunity and agrees to submit all relevant clinical information with the appeal. Re-review appeal requests will not be accepted.
Sample 1
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Standard Appeals. (i) Appeals shall be decided, and written notice sent to the beneficiary as expeditiously as the beneficiary’s health requires and not more than 30 days after receipt of the internal appeal. The 30-day period begins with the receipt of the internal appeal and includes any review at the level of the Designated Agency(DA)/Specialized Service Agency (SSA).If an appeal cannot be resolved within 30 days, the timeframe may be extended up to an additional 14 days by request of the beneficiary, or by DVHA, if DVHA demonstrates (including to the satisfaction of AHS, upon its request) that there is a need for additional information and how the extension is in the best interest of the beneficiary. If the timeline is extended, DVHA must resolve the appeal as expeditiously as the beneficiary’s health condition requires and not later than the date the extension expires. (ii) If DVHA extends the time frame and it is not at the request of the beneficiary, DVHA must make reasonable efforts to give the beneficiary prompt oral notice of the delay and, within 2 calendar days, must give the beneficiary written notice of the reason for the decision to extend the timeframe and inform the beneficiary of the right to file a grievance if s/he disagrees with the decision to extend the timeline. DocuSign Envelope ID: F73EF454-508D-44AC-ABD8-2A528194331A
Sample 1
Standard Appeals. Any decision made by EB ESP to deny, reduce or terminate a service or to deny payment for a service will be provided to you orally and in writing and will include an explanation of our reasons for the denial along with an explanation of your appeal rights. Be sure to address the FAX to EB ESP Compliance Director.
Sample 1
Standard Appeals. Any decision made by ESP of HHSI to deny, reduce or terminate a service or to deny payment for a service will be provided to you orally and in writing and will include an explanation of our reasons for the denial along with an explanation of your appeal rights.
Sample 1
Standard Appeals. The Contractor’s Appeals process must include the following requirements:
Sample 1
Standard Appeals. You may file a formal written Appeal of an Adverse Benefit Determination with Coventry Health Care of Utah Grievances and Appeals Department. Any individual You designate as an authorized representative, including Your health care Provider, may also write an Appeal on Your behalf. A written Appeal must be filed no later than one-hundred eighty (180) calendar days from the date You received notification of the Adverse Benefit Determination. Coventry Health Care of Utah’s review of the Appeal will be based only on the information You provide, such as medical records. The Grievances and Appeals Department will investigate the issue, and submit the Appeal with all relevant information to the appropriate Appeals committee for review and determination. You or Your authorized representative may review the claim file and present information to the committee in writing or by telephone. None of the committee members will have been involved in the initial decision. The Appeals committee will notify You in writing of the decision within the following timeframes:  Post Service Claims (services have already been obtained) – sixty (60) days from receipt of Your Appeal  Pre Service Claims (services that have not been obtained) – thirty (30) days from receipt of Your Appeal If the Appeals committee intends to uphold the initial denial after reviewing the Appeal, Coventry Health Care of Utah will provide You with any new or additional information or rationale considered in the Appeal process. The information will be given to You as soon as possible, to allow You to respond prior to the date the committee’s final decision is due. Any additional information You choose to provide in response will be presented to the Appeals committee for a final decision.
Sample 1
Standard Appeals. Appeals shall be decided, and written notice sent to the beneficiary as expeditiously as the beneficiary’s health requires and not more than 30 days after receipt of the internal appeal. The 30-day period begins with the receipt of the internal appeal and includes any review at the level of the Designated Agency(DA)/Specialized Service Agency (SSA).
Sample 1
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Related to Standard Appeals

  • 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. 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.

  • Disciplinary Appeals All forms of disciplinary action which are not appealable to the Civil Service Commission or the courts, except written or oral reprimands and Forms 475, shall be subject to review through Steps 3, 4, 5 and 6 of the grievance procedure.

  • 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: (1) The Administrator's decision on appeal. (2) The specific reasons for the decision. (3) The specific provisions of the Agreement on which the decision is based. Notice of the Administrator's decision shall be given within 60 days of the Claimant's written request for review, unless additional time is required due to special circumstances. In no event shall the Administrator render a decision on an appeal later than 120 days after receiving a request for a review.

  • Complaints and Appeals As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

  • Review Procedure If the Plan Administrator denies part or all of the claim, the claimant shall have the opportunity for a full and fair review by the Plan Administrator of the denial, as follows:

  • 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.

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