Formal Appeal definition

Formal Appeal. An appeal of an Adverse Benefit Determination filed either orally or in writing which HPN’s Customer Response and Resolution Department investigates. If a Formal Appeal is resolved to the satisfaction of the Member, the appeal is closed. The Formal Appeal is mandatory if the Member is not satisfied with the initial determination and the Member wishes to appeal such determination.
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Examples of Formal Appeal in a sentence

  • You have 30 days from the date you receive notice that your denial was upheld at the Formal Appeal level to request an External Independent Review.

  • If Cigna Dental upholds the denial, the notice will include a description of the criteria used, the clinical reasons for the decision, references to any supporting documentation, and notice of your right to proceed to a Formal Appeal.

  • A 2nd Level Formal Appeal not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which it relates.

  • Exhaustion of the 1st Level Formal Appeal procedure is a precondition to filing a 2nd Level Formal Appeal.

  • When an Informal Review is not resolved in a manner that is satisfactory to the Member or when the Member chooses not to file an Informal Review and the Member wishes to pursue the matter further, the Member must file a 1st Level Formal Appeal.

  • When the investigation is complete, the Member will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal.

  • If Cigna Dental upholds the denial of a pre- authorization or a claim for services already providedat the Formal Appeal level, you may seek an External Independent Review.

  • The 2nd Level Formal Appeal is voluntary for all Adverse Benefit Determinations.

  • If the determination of the Informal Review is not acceptable to the Member and the Member wishes to pursue the matter further, the Member may file a 1st Level Formal Appeal.

  • The Member will be informed of this right at the time the Member is informed of the resolution of his 1st Level Formal Appeal.

Related to Formal Appeal

  • Final Approval Order and Judgment means an order and judgment that the Court enters after the Final Approval Hearing, which finally approves the Settlement Agreement, certifies the Settlement Class, dismisses the Action with prejudice, and otherwise satisfies the settlement-related provisions of Federal Rule of Civil Procedure 23, and is consistent with all material provisions of this Agreement, substantially in the form annexed hereto as Exhibit 5.

  • Appeal means a request for a review of the Floodplain Administrator's interpretation of any provision of this ordinance.

  • Formal Dispute means a written objection by an Interested Party to any of the following: i. A solicitation or other request by OGS for offers for a contract for the procurement of commodities, services or technology. ii. The cancellation of the solicitation or other request by OGS. iii. An award or proposed award of the Contract by OGS. iv. A termination or cancellation of an award of the Contract by OGS. v. Changes in the scope of the Centralized Contract by the Commissioner. vi. Determination of “materiality” in an instance of nonperformance or contractual breach. vii. An equitable adjustment in the Centralized Contract terms and/or pricing made by the Commissioner during a Force Majeure event.

  • Formal complaint means a document filed by a complainant or signed by the Title IX Coordinator alleging sexual harassment against a respondent and requesting an investigation of the allegation of sexual harassment.

  • Formal hearing means a board or department process that provides for the right of private parties to submit factual proofs as provided in § 2.2-4020 of the Administrative Process Act in connection with case decisions. Formal hearings do not include the factual inquiries of an informal nature provided in § 2.2-4019 of the Administrative Process Act.

  • Expedited Appeal means if a Member appeals a decision regarding a denied request for Prior Authorization (Pre-Service Claim) for an Urgent Care Claim, the Member or Member’s Authorized Representative can request an Expedited Appeal, either orally or in writing. Decisions regarding an Expedited Appeal are generally made within seventy-two (72) hours from the Plan’s receipt of the request.

  • Final Approval Hearing means the hearing before the Court where the Parties will request the Final Judgment to be entered by the Court approving the Settlement Agreement, the Fee Award, and the incentive award to the Class Representative.

  • Board of appeals means the local board of appeals as created by local ordinance.

  • Final Approval Order means the proposed Order Granting Final Approval to the Settlement, to be entered by the Court with terms to be agreed upon by the Parties and consistent with this Agreement.

  • Final Decision means a final action of the commission determining the legal rights, duties, or privileges of any person. “Final decision” does not include preliminary, procedural, or intermediate actions by the commission, actions regulating the internal administration of the commission, or actions of the commission to enter into or refrain from entering into contracts or agreements with vendors to provide goods or services to the commission.

  • Formal proceedings means proceedings conducted before a judge with notice to interested persons.

  • Final Approval means the Court’s order granting final approval of the Settlement.

  • Joint Remediation Committee has the meaning set forth in Section II.A.2.

  • Appeal Board means the State Charter School Appeal

  • Notice of Appeal means a notice given pursuant to Condition 6.2.

  • Review Board has the meaning provided in Section 2.1(f)(i) of this Commercial Shared-Loss Agreement.

  • Competent Supervisory Authority means a supervisory authority which has jurisdiction in relation to the activities of a controller or processor under European data protection law in a particular Member State;

  • Reconsideration means review by the director of an insurer’s Notice of Closure.

  • Appeals Tribunal or “AT” means the Body responsible for hearing and determining appeals set out in section 9;

  • Appeals Board means the commissioners and deputy commissioners of the Workers’ Compensation Appeals Board acting en banc, in panels, or individually.

  • Final Order and Judgment means the final judgment and order of dismissal with prejudice to be entered in the Lawsuit in connection with the approval of the Settlement after the Final Approval Hearing.

  • Adjudicatory hearing means a hearing to determine:

  • Court of Appeal means the division of the Supreme Court referred to in section 7(1)(b);

  • Appeal Tribunal means the all-citizen Tribunal duly appointed by Council to conduct hearings under this By-law; (200-08)

  • Adjudicating Authority or “NCLT” shall mean the Hon’ble Chennai Bench of the National Company Law Tribunal;

  • Appeal Committee means the appeal committee established by the Council in terms of section 12(3)(a);