Standard Appeals Process Sample Clauses

Standard Appeals Process. The standard Appeal process includes the following:
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Standard Appeals Process. 8.4.4. 1 An Enrollee who disagrees with a decision or Action communicated on a Notice of Action may file an Appeal orally or in writing.
Sample 1
Standard Appeals Process. All of the staff at Rocky Mountain PACE share responsibility with you, your family or caregiver in providing you the comprehensive health care services identified in your Plan of Care as authorized by the Interdisciplinary Team. You, your family or caregiver are encouraged to contact a member of the Interdisciplinary Team when you have a disagreement with Rocky Mountain PACE’s non-coverage, reduction in services, or of nonpayment for a service. If we deny your request for a service or for payment of a claim, we will give you a written copy of this information on the appeals process, including a form that you may use to request your appeal. You may also make your appeal known verbally, and PACE staff will document and submit your request for an appeal. The Rocky Mountain PACE Quality Assurance Manager or designee will respond to you in writing within two working days, stating that your appeal has been received. A person not involved in our initial decision to deny your request for a service or to pay a claim will reevaluate your appeal. The reviewer will be an appropriately credentialed and impartial individual who was not involved in the original action and does not have a stake in the outcome of the appeal. You or your authorized representative may present or submit to us relevant facts and/or evidence for review, either in person or in writing for consideration during the appeal process. Within thirty (30) calendar days of receiving the appeal, Rocky Mountain PACE will notify you by certified mail of the appeals decision. A copy of the notification will be kept in your file. Rocky Mountain PACE may not stop or reduce services while your appeal is pending. If the appeal is not resolved in your favor, you may be charged for the cost of the services. How to request an expedited appeal: Rocky Mountain PACE has an expedited appeal process for situations in which you, or your family or caregiver believe your life, health, or ability to regain maximum function would be seriously jeopardized, absent provision of the service in dispute: • You or your authorized representative may present or submit relevant facts and/or evidence for review, to support your request for an expedited appeal. • The Quality Assurance Department will respond to your request for an expedited appeal within 24 hours and notify you if your appeal has been found to meet the criteria for expediting an appeal. • For expedited appeals you will be notified in writing, in the same manner as descr...
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Standard Appeals Process 
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Related to Standard Appeals Process

  • Appeals Process A. The Contractor’s appeal process shall, at a minimum:

  • 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:

  • 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.

  • Claims Process (1) In order to seek payment from the Settlement Amount, a Class Member must submit a completed Claim Form to the Administrator, in accordance with the provisions of the Plan of Allocation, on or before the Claims Bar Deadline and any Class Member who fails to do so shall not share in any distribution made in accordance with the Plan of Allocation unless the relevant court orders otherwise as provided in section 18.4.

  • Review Process A/E's Work Product will be reviewed by County under its applicable technical requirements and procedures, as follows:

  • 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.

  • COMPLAINT AND GRIEVANCE PROCEDURE 1. When a member of the bargaining unit has any grievance or complaint, he shall forthwith convey to his immediate superior, orally with or without a member of the Association Executive or in writing, all facts relative to the grievance and/or complaint. The member and the superior shall make every attempt to resolve the problem at this preliminary stage.

  • CENTRAL GRIEVANCE PROCEDURE 15.1 Effective until April 30, 2019, this procedure applies to differences:

  • Grievance Procedure - Party In the case of all other grievances by a party, (including those on behalf of a group of Members, an individual Member, a retired Member or a deceased Member), the party making the grievance may take the following steps in sequence to resolve the matter after the matter has been discussed informally with the other party. The informal discussion shall occur with the Administrator of Employee Relations.

  • Complaints Procedure 18.1 If the Client has any cause for complaint in relation to the services provided by the Company, he should file a complaint as per the Company’s Complaint Handling policy which is available on the Company’s website.

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