Timeframes for Internal Review of Adverse Determinations Sample Clauses

Timeframes for Internal Review of Adverse Determinations. Upon receipt of a request for internal review of an Adverse Determination, we shall conduct either a standard or expedited review, as appropriate.  Expedited review. We shall complete our internal review as required by the medical exigencies of the case but in no case later than seventy-two (72) hours from the time the internal review request was received whenever:  Your life or health would be jeopardized.  Your ability to regain maximum function would be jeopardized.  The Practitioner/Provider reasonably requests an expedited decision.  In the opinion of the Practitioner/Provider with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim or  The medical exigencies of the case require an expedited decision.  Standard review. We shall complete a standard review of both internal reviews as described in state laws within twenty (20) working days of receipt of the request for internal review in all cases in which the request for review is made prior to the service requested, and does not require expedited review, and within forty (40) working days of receipt of the request in all post-service requests for internal review. We may extend the review period for a maximum of ten (10) working days in pre-service cases, and twenty (20) working days for post-service cases if we:  can demonstrate reasonable cause beyond its control for the delay,  can demonstrate that the delay will not result in increased medical risk to you and  provide a written progress report and explanation for the delay to your Practitioner/Provider within the original thirty (30) days for pre-service or sixty (60) days for post-service review period,  if the Grievance contains clearly divisible Administrative and Adverse Decision issues, then we shall initiate separate complaints for each decision.  Failure to comply with deadline. If we fail to comply with the deadline for completion of an internal review, the requested Health Care Service shall be deemed approved unless you, after being fully informed of your rights, have agreed in writing to extend the deadline. Internal Panel Review of Adverse DeterminationsSelection of an internal review panel. In cases of Appeal from an Adverse Determination or from a third party administrator’s decision to uphold an Adverse Determination, we shall select an internal review panel to review the Adverse Determination or the decisi...
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Related to Timeframes for Internal Review of Adverse Determinations

  • External Review In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact XxXxx’s Member Engagement Center.

  • Office of Inspector General Investigative Findings Expert Review In accordance with Senate Bill 799, Acts 2021, 87th Leg., R.S., if Texas Government Code, Section 531.102(m-1)(2) is applicable to this Contract, Contractor affirms that it possesses the necessary occupational licenses and experience.

  • Standard of Review The Parties acknowledge and agree that the standard of review for any avoidance, breach, rejection, termination or other cessation of performance of or changes to any portion of this integrated, non-severable Agreement (as described in Section 22) over which FERC has jurisdiction, whether proposed by Seller, by Buyer, by a non-party of, by FERC acting sua sponte shall be the “public interest” standard of review set forth in United Gas Pipe Line Co. v.

  • GUIDELINES FOR REVIEWS We may provide you areas on the Site to leave reviews or ratings. When posting a review, you must comply with the following criteria:

  • AUDIT REVIEW PROCEDURES A. Any dispute concerning a question of fact arising under an interim or post audit of this AGREEMENT that is not disposed of by AGREEMENT, shall be reviewed by LOCAL AGENCY’S Chief Financial Officer.

  • Technical Objections to Grievance No grievance will be defeated or denied by any minor technical objection.

  • 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.

  • PURPOSE/JUSTIFICATION OF RECOMMENDED ACTION The purpose of the Agreement is to provide the City with the services for one full-time equivalent senior criminalist from the Department to perform DNA testing, analysis, and forensic-related consulting as requested by the City, effective July 1, 2016 through June 30, 2021. The City’s current agreement with the County for this position expires on June 30, 2016. This Agreement will not result in the creation of an additional senior criminalist position, as the position was created during the previous agreement.

  • INDEPENDENT PRICE DETERMINATION 6.1 By signing and submitting this bid, the Bidder certifies that the prices in this bid have been arrived at independently, without consultation, communication or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor; unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the Bidder prior to bid opening directly or indirectly to any other Bidder or to any competitor; no attempt has been made, or will be made, by the Bidder to induce any person or firm to submit, or not to submit, a bid for the purpose of restricting competition.

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

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