Examples of Appeal Procedures in a sentence
Any of the authority and responsibilities of the Plan Administrator under the Claims and Appeal Procedures or the External Review Process, including the discretionary authority to interpret the terms of the Plan, may be delegated to a third party.
Denials based on Experimental/Investigational services and supplies are Adverse Determinations and are subject to the utilization review process, including reviews by an Independent Review Organization (IRO) as described in the Complaint and Appeal Procedures section.5. Any charges resulting from the failure to keep a scheduled visit with a Participating Provider or for acquisition of medical records.6. Special medical reports not directly related to treatment.
Denials based on Experimental/Investigational services and supplies are Adverse Determinations and are subject to the utilization review process, including reviews by an Independent Review Organization (IRO) as described in the Complaint and Appeal Procedures section of the EOC.
See the External Appeal Procedures provision for additional information about filing an external Appeal.Concurrent Care Claims Concurrent Care Claims are requests that Health Plan continue to approve an ongoing course of covered treatment to be provided over a period of time or number of treatments, when the course of treatment prescribed will either:1.
The following claim definitions have special meaning when used in this Plan in accordance with Claim Procedures and Appeal Procedures.
The Principles of Natural Justice and Procedural Fairness must prevail in Appeal Procedures to ensure compliance with the principle that justice must not only be done, but be seen to be done.
You may obtain a review of the denial by following the process set out in Complaint and Appeal Procedures.
This is in accordance with the appeal process that is available to the candidate (see sub-section on Appeal Procedures).
APPEAL PROCEDURESA summary of the Appeal Procedures is presented in the chart following this section.
If the Participant has additional information that he believes could change the decision, send it to Us and request a review of the decision as described in Claim Appeal Procedures below.