External Appeal Agent definition

External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. General Dentist: A dentist licensed under Title 8 of the New York State Education Law (or other comparable state law, if applicable) who is not a Specialist.
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External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: • Is primarily engaged in providing, by or under the continuous supervision of Physicians, to patients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons; • Has organized departments of medicine and major surgery; • Has a requirement that every patient must be under the care of a Physician or dentist; • Provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.); • If located in New York State, has in effect a Hospitalization review plan applicable to all patients which meets at least the standards set forth in 42 U.S.C. Section 1395x(k); • Is duly licensed by the agency responsible for licensing such Hospitals; and • Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care. Hospital does not mean health resorts, spas, or infirmaries at schools or camps. Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Copayment: A fixed amount You pay directly to a Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service. In-Network Deductible: The amount You owe before We begin to pay for Covered Services received from Participating Providers or Preferred Providers. The In-Network Deductible applies before any Copayments or Coinsurance are applied. The In-Network Deductible may not apply to all Covered Services. You may also have an In-Network Deductible that applies to a specific Covered Service that You owe before We begin to pay for a particular Covered Service. Medically Necessary: See the How Your Coverage Works section of this Contract for the definition. Medicare: Title XVIII of the Social Sec...
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External Appeal Agent means an entity certified by the superintendent pursuant to Section 4911 of the New York Insurance Law.
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Examples of External Appeal Agent in a sentence

  • In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application.

  • If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Policy.

  • In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application.

  • However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State.

  • The External Appeal Agent must notify You in writing of its decision within two (2) business days.

  • The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision.

  • The External Appeal Agent must also notify You in writing of its decision.

  • If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision.

  • If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent.

  • Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision.

Related to External Appeal Agent

  • Internal appeal means an internal appeal to the relevant authority in terms of section 74;

  • External Auditor as used here shall mean any registered public accounting firm engaged for the purpose of preparing or issuing an audit report or performing other audit, review or attest services for the Company. Each such external auditor shall report directly to the Committee. With respect to the external auditor, the Committee shall:

  • External dose means that portion of the dose equivalent received from any source of radiation outside the body.

  • Internal Auditor means the person employed or engaged by the Corporation to perform the internal audit function of the Corporation;

  • Internal audit means an independent appraisal activity established within a state agency as a control system to examine and evaluate the adequacy and effectiveness of other internal control systems within the agency.

  • Internal dose means that portion of the dose equivalent received from radioactive material taken into the body.

  • External Account is your account at another financial institution (i) to which you are transferring funds from your Eligible Transaction Account; or (ii) from which you are transferring funds to your Eligible Transaction Account.

  • external borders means external borders as defined in Article 2(2) of Regulation (EU) 2016/399;

  • Internal Procedures means in respect of the making of any one or more entries to, changes in or deletions of any one or more entries in the register at any time (including without limitation, original issuance or registration of transfer of ownership) the minimum number of the Warrant Agent’s internal procedures customary at such time for the entry, change or deletion made to be complete under the operating procedures followed at the time by the Warrant Agent, it being understood that neither preparation and issuance shall constitute part of such procedures for any purpose of this definition;

  • Internal inspection means as complete an examination as can reasonably be made of the internal surfaces of a boiler or pressure vessel while it is shut down and manhole plates, handhole plates or other inspection opening closures are removed as required by the Authorized Inspector.

  • Enforcement Procedures means the procedures for the enforcement of Mortgages from time to time in accordance with the relevant Seller’s Policy;

  • External inspection means an inspection made when a boiler is in operation.

  • Internal Market Buyer means a Market Buyer making purchases of energy from the PJM Interchange Energy Market for ultimate consumption by end-users inside the PJM Region that are served by Network Transmission Service.

  • External User means a user of an Online Service that is not an employee, onsite contractor, or onsite agent of Customer or its Affiliates.

  • Automated external defibrillator means a defibrillator device to which all of the following apply:

  • External Market Buyer means a Market Buyer making purchases of energy from the PJM Interchange Energy Market for consumption by end-users outside the PJM Region, or for load in the PJM Region that is not served by Network Transmission Service.

  • external wall means an outer wall of a building even though adjoining to a wall of another building and also means a wall abutting on an interior open space of a building;

  • external engineering service means an engineering service situated outside the boundaries of a land area and that is necessary to serve the use and development of the land area;

  • Safeguards Monitoring Report means each report prepared and submitted by the Borrower to ADB that describes progress with implementation of and compliance with the EMP and the RP (as applicable), including any corrective and preventative actions;

  • Internal combustion engine or ‘engine’ means an energy converter, other than a gas turbine, designed to transform chemical energy (input) into mechanical energy (output) with an internal combustion process; it includes, where they have been installed, the emission control system and the communication interface (hardware and messages) between the engine's electronic control unit(s) and any other powertrain or non-road mobile machinery control unit necessary to comply with Chapters II and III;

  • internal waters means any navigable river or waterway within the State of California.

  • external company means a foreign company that is carrying on business, or non-profit activities, as the case may be, within the Republic, subject to section 23(2);

  • External Verifier means PricewaterhouseCoopers SpA or any such other qualified provider of third party assurance or attestation services or other independent expert of internationally recognised standing appointed by the Issuer, in each case with the expertise necessary to perform the functions required to be performed by the External Verifier under these Conditions, as determined in good faith by the Issuer.

  • Internal Controls for districts means processes designed and im- plemented by districts to provide reasonable assurance regarding the achievement of objectives in the following categories: