External Grievance definition

External Grievance. A Grievance that is filed with CMS and/or the State. This is not an Appeal.
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External Grievance. The Contract shall inform Enrollees that they may file an external grievance for Medicare only covered benefits and services through 1-800 Medicare or for Medicare and Medi-Cal covered benefits and services through the Cal MediConnect Ombuds program. The Contractor must display a link to the electronic grievance form on the Xxxxxxxx.xxx Internet Web site on the Contractor’s main web page. 42 C.F.R. § 422.504(a)(15)(ii). The Contractor must inform Enrollees of the email address, postal address or toll-free telephone number where an Enrollee grievance may be filed.
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External Grievance. A grievance that is filed with CMS and/or the State. Flexible Benefits – Benefits MMPs may choose to offer outside of the required Covered Services. Long-Term Services and Supports (LTSS) – A range of medical, social, or rehabilitation services a person needs over months or years in order to improve or maintain function or health, which are provided in the community or in a long-term care facility such as a nursing facility. Grievance – In accordance with 42 CFR Part 438.400, grievance means an expression of dissatisfaction about any matter other than an “Action.” A grievance is filed and decided at the MMP level. Possible subjects for grievances include, but are not limited to, the quality of care or services provided and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Enrollee’s rights.
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Examples of External Grievance in a sentence

  • External Grievance Appeal Reviews Issues involving medical judgment (Grievance) or a rescission of coverage (except for non-payment of premiums) are coordinated by the plan in full compliance with the federally administered private accredited Independent Review Organization (IRO) process as required by Health Care Reform.

  • The Internal (Worker) and External Grievance Mechanisms will be implemented by relying on the following key principles for all the Project-related comments, issues, and complaints internally and externally.

  • The External Grievance Officer is a person of demonstrable authority and experience in Higher Education, who is not otherwise employed by SCD or any MI.

  • The Member or the filing Health Care Provider may supply additional information to the CRE, with copies to the Plan, for consideration in the External Grievance Appeal Review within fifteen (15) calendar days of filing the request with the Plan.

  • An Enrollee also may file an External Grievance at any time by calling or writing to MassHealth.

  • The Plan shall contact the Member or the Health Care Provider who filed the External Grievance Appeal and the Department of Health within five (5) business days of the filing of the External Grievance Appeal.

  • In order to request an external appeal, the Member must contact the HMO at the following address, fax and telephone numbers: HMO External Grievance Review X.X. Xxx 000000 Xxxxxxxxxx, XX 00000-0000 Fax: 000-000-0000 Toll-free: 0-000-000-0000 TTY: 711 Within five (5) business days of receipt of the Member’s request, the HMO will forward the Member’s request to a randomly assigned IRO.

  • The External Grievance Appeal Review shall be completed and a decision rendered within sixty (60) calendar days of the request and a written response shall be provided to the Member and the filing Health Care Provider, the Plan and the Department.

  • Within fifteen (15) calendar days of the receipt of the request for an External Grievance Appeal, the Plan shall forward copies of all written documentation regarding the Member’s Grievance to the CRE assigned to perform the External Grievance Appeal.

  • Notification to the Member and filing Health Care Provider shall include the basis for the decision and information that the Member or the filing Health Care Provider will have sixty (60) calendar days from receipt of the decision of the External Grievance Appeal Review to appeal to a court of competent jurisdiction.


More Definitions of External Grievance

External Grievance. A grievance with an adverse decision at the FIDA Plan level that is filed with CMS and/or the State. Facility-based Long-Term Services and Supports (LTSS) – Facility-based LTSS are a range of medical, social, or rehabilitation services a person needs over months or years in order to improve or maintain function or health which are provided in a long term care facility such as a nursing home (not including Assisted Living Residences).
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External Grievance. A Grievance that is filed with CMS and/or the State. This is not an Appeal. N.Y. Mental Hygiene Law. § 1.03(22).
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External Grievance means independent review of a grievance and “Department” is the Indiana department of insurance.
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Related to External Grievance

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

  • 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);

  • Group Grievance is defined as a single grievance, signed by a Xxxxxxx or a Union Representative on behalf of a group of employee who have the same complaint. Such grievances must be dealt with at successive stages of the Grievance Procedure commencing with Step 1. The grievors shall be listed on the grievance form.

  • External Verifier means a qualified provider of third-party assurance or attestation services appointed by the Guarantor to review the Guarantor's statement of the Sustainability Performance Targets.

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

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

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

  • Grievance means a complaint in writing that an employee, group of employees, or the Union submits to management, to be processed through the grievance procedure.

  • 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:

  • Policy Grievance shall be signed by a xxxxxxx or a Union representative or, in the case of an Employer's policy grievance, by the Employer or its representative.

  • External Manager means either of the following: (1) A person who is seeking to be, or is, retained by a board or an investment vehicle to manage a portfolio of securities or other assets for compensation, or (2) A person who manages an investment fund and who offers or sells, or has offered or sold, an ownership interest in the investment fund to a board or an investment vehicle.

  • Personal Grievance means a claim that an employee: (a) Has been unjustifiably dismissed; or (b) has had his/her employment, or his/her conditions of employment, affected to (c) his/her disadvantage by some unjustifiable action by the employer; or (d) has been discriminated against in his/her employment; or (e) has been sexually harassed in his/her employment; or (f) has been racially harassed in his/her employment; or (g) has been subjected to duress in relation to union membership.

  • 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 Directors means as defined in the Companies Law.

  • External Resource means a generation resource located outside the metered boundaries of the PJM Region.

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

  • Statement of Grievance shall name the grievant(s) involved, the facts giving rise to the grievance, the provision(s) of the Agreement alleged to be violated, and the remedy (specific relief) requested.

  • Internal Use means use of the Sprinklr Services for Customer’s and/or Customer Affiliates’ general business use, solely for the benefit of Customer and/or Customer Affiliates, but does not include use of the Sprinklr Services to provide any services for the benefit of third parties.

  • A grievance means a dispute or disagreement as to the interpretation or application of terms and conditions of employment contained in this Agreement.

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

  • 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;

  • External Review means an independent review of an Adverse Benefit Determination conducted by an Independent Review Organization.

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

  • 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;

  • Internal Systems means the internal systems of each of the Corporation that are presently used in its Business or operations, including, computer hardware systems, software applications and embedded systems.

  • 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.