Grievance and Appeals System definition

Grievance and Appeals System means the overall system that includes Grievances and Appeals handled at the MCO, and access to the State Fair Hearing process.
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Grievance and Appeals System means an overall system that includes a Grievance process, an Appeal process, and access to the Medicaid State’s fair hearing system. Health Care-Acquired Condition or HAC means a condition occurring in any inpatient hospital setting, defined as a HAC by the Secretary of Health and Human Services under Section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program identified in the State Plan as described in Section 1886(D)(4)(D)(ii) and (iv) of the Act; other than Deep Vein Thrombosis(DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients.
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Grievance and Appeals System means an overall system that includes a Grievance process, an Appeal process, and access to the State’s fair hearing system. Health Insurer Fee means the annual fee the Contractor is required to pay pursuant to Section 9010 of the Patient Protection and Affordable Care Act.
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Examples of Grievance and Appeals System in a sentence

  • PCS shall ensure that the individuals who make decisions on grievances follow all requirements in OAR 410-141-3875 MCE Grievance and Appeals System General Requirements.

  • Grievance and Appeals System procedures as described in Section 41.400.

  • This3 Agreement applies only to Anthem’s Grievance and Appeals System for its commercial lines4 of business, excluding dental, and does not apply to any line of business where regulation5 by the Department is preempted by federal law.6 ACKNOWLEDGEMENTS7 15.

  • The Grievance System Coordinator ensures our Member Grievance and Appeals System is responsive to the needs of our members.

  • However, understandably, the TEACH Act failed to anticipate the explosion of other models for the delivery of digital educational experiences to learners.

  • The Division Director of Human Resources will be responsible for the development, implementation, management, and administration of an Employee Grievance and Appeals System (EGAS) applicable to all covered employees of the South Carolina Department of Corrections (SCDC).

  • Activity 6: Monitor Effectiveness of Grievance and Appeals System Standards and Requirements The Federal government requires the MCOs operate internal systems for receiving and resolvingmembers’ grievances and appeals, in 42 CFR 438, Subpart F.

  • Code Regs., Title 28, §1300.68(a)(4)(d)(2)) Plan policy G&A-001 Grievance and Appeals System Description (revised 1/21/20) stated the Plan would ensure each issue is addressed and resolved when a complainant presents with multiple issues.

  • Activity 1 description: PCS-MP will improve the Grievance and Appeals System by working with NEMT subcontractors to initiate interventions to ensure timely member pick-up.

  • The policy, "Member Grievance and Appeals System Description," states that if Home State Health fails to adhere to the notice and timing requirements under section 2.12.16 c(22) of the MHD contract, the member is deemed to have exhausted Home State Health's internal level of appeal and may initiate a State Fair Hearing.


More Definitions of Grievance and Appeals System

Grievance and Appeals System means the process the Contractor implements to handle Appeals of an Adverse Benefit Determination, Grievances, as well as the process to collect and track information about them. Health Care-Acquired Condition or HAC means a condition occurring in any inpatient hospital setting, defined as a HAC by the Secretary of Health and Human Services under Section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program identified in the State Plan as described in Section 1886(D)(4)(D)(ii) and (iv) of the Act; other than Deep Vein Thrombosis(DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients. Health Insuring Organization (HIO) means a county operated entity, that in exchange for Capitation Payments, covers services for beneficiaries
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Grievance and Appeals System means the process the Contractor implements to handle Appeals of an Adverse Benefit Determination, Grievances, as well as the process to collect and track information about them. Health Care-Acquired Condition or HAC means a condition occurring in any inpatient hospital setting, defined as a HAC by the Secretary of Health and Human Services under Section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program identified in the State Plan as described in Section 1886(D)(4)(D)(ii) and (iv) of the Act; other than Deep Vein Thrombosis(DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients. Health Insuring Organization (HIO) means a county operated entity, that in exchange for capitation payments, covers services for beneficiaries (1) through payments to, or arrangements with, providers; (2) under a Comprehensive Risk Contract with the State; and (3) meets the following criteria: (i) first became operational prior to January 1, 1986; or (ii) is described in section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985 (as amended by section 4734 of the Omnibus Budget Reconciliation Act of 1990 and section 205 of the Medicare Improvements for Patients and Providers Act of 2008).
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Grievance and Appeals System means means the process the Contractor implements to handle Appeals of an Adverse Benefit Determination, Grievances, as well as the process to collect and track information about them. Health Insuring Organization (HIO) means a county operated entity, that in exchange for capitation payments, covers services for beneficiaries (1) through payments to, or arrangements with, providers; (2) under a Comprehensive Risk Contract with the State; and (3) meets the following criteria: (i) first became operational prior to January 1, 1986; or (ii) is described in section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985 (as amended by section 4734 of the Omnibus Budget Reconciliation Act of 1990 and section 205 of the Medicare Improvements for Patients and Providers Act of 2008).
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Grievance and Appeals System means an overall system that includes a Grievance process, an Appeal process, and access to the Medicaid State’s fair hearing system. Health Care-Acquired Condition or HAC means a condition occurring in any inpatient hospital setting, defined as a HAC by the Secretary of Health and Human Services under Section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program identified in the State Plan as described in Section 1886(D)(4)(D)(ii) and (iv) of the Act; other than Deep Vein Thrombosis(DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients. Health Insuring Organization (HIO) means a county operated entity, that in exchange for capitation payments, covers services for beneficiaries (1) through payments to, or arrangements with, providers; (2) under a comprehensive risk contract with the State; and (3) meets the following criteria: (i) first became operational prior to January 1, 1986; or (ii) is described in section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985 (as amended by section 4734 of the Omnibus Budget Reconciliation Act of 1990 and section 205 of the Medicare Improvements for Patients and Providers Act of 2008).
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Related to Grievance and Appeals System

  • Grievance System means the overall system that includes:

  • Policy Grievance is defined as a difference between the parties relating to the interpretation, application or administration of this Agreement. A policy grievance may be submitted by either party at Step 2 of the grievance procedure. A policy grievance shall be signed by a CLAC Representative and submitted to the Employer. A policy grievance submitted by the Employer shall be signed by the Employer or his representative.

  • Division of hearings and appeals means the division of hearings and appeals in the department of administration.

  • Grievance means a dispute arising out of the interpretation, application, administration or alleged violation of the terms of this Agreement.

  • Grievance Procedure is used in this Agreement, it shall be considered as including the arbitration procedure.

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

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

  • Grievance Committee means the Grievance Committee of the Bar.

  • Managed care plan means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier.

  • Complaints Procedure means the School's procedure for handling complaints from parents, as amended from time to time for legal or other substantive reasons, or in order to assist the proper administration of the School. It does not form part of the contract between you and the School. A copy of the most up-to-date procedure is on the School's website and is otherwise available from the School at any time upon request;

  • 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.

  • Service Complaints For service problems or complaints, you should contact your local utility by calling: AEP Ohio at 000.000.0000. IN THE EVENT OF AN ENERGY-RELATED EMERGENCY, SUCH AS A POWER OUTAGE OR DOWNED POWER LINE, PLEASE VACATE THE AREA BY A SAFE DISTANCE AND CALL YOUR LOCAL UTILITY or 911. Authorization/Representation/Letter of Agency:By entering into this Agreement, you authorize XOOM to act on your behalf under your local utility’s tariffs in accordance with the rules and regulations of the PUCO. You acknowledge that you are your local utility account holder, or a person legally authorized to execute this Agreement on behalf of the account holder for electricity service and are at least eighteen (18) years of age. You agree to authorize XOOM to obtain your credit information and you agree to authorize your local utility to release all information relating to your historical and current electricity usage, billing and payment history to XOOM or its authorized representatives. You acknowledge that XOOM has full authority to make all rates and tariff selections necessary to meet its obligations under this Agreement. You may rescind this authorization at any time by contacting XOOM. Neither your social security number, customer account number nor any other customer financial information will be released by XOOM, except where such release is required by court order or by Commission Order or Rule, without your affirmative written consent. Execution of this Agreement shall constitute authorization for the release of this information to XOOM.

  • Quality improvement organization or “QIO” shall mean the organization that performs medical peer review of Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy and quality of care; appropriateness of admission, discharge and transfer; and appropriateness of prospective payment outlier cases. These activities undertaken by the QIO may be included in a contractual relationship with the Iowa Medicaid enterprise.

  • Mobile crisis outreach team means a crisis intervention service for minors or families of minors experiencing behavioral health or psychiatric emergencies.

  • Adverse System Impact means a negative effect that compromises the safety or reliability of the electric distribution system or materially affects the quality of electric service provided by the electric distribution company (EDC) to other customers.

  • Claims Process means the process for Settlement Class Members’ submission of Claims, as described in Section III.

  • Data Protection Impact Assessment means an assessment by the Controller of the impact of the envisaged processing on the protection of Personal Data.

  • Public safety answering point or “PSAP” means an answering location for 9-1-1 calls originating in a given area. A PSAP may be designated as Primary or Secondary, which refers to the order in which calls are directed for answering. Primary PSAPs respond first; Secondary PSAPs receive calls on a transfer basis only, and generally serve as a centralized answering location for a particular type of emergency call. PSAPs are staffed by employees of Service Agencies such as police, fire or emergency medical agencies or by employees of a common bureau serving a group of such entities.

  • Claims Procedure Order means the Order under the CCAA establishing a claims procedure in respect of the Applicant, as same may be further amended, restated or varied from time to time.

  • Environmental and Social Management Plan or “ESMP” means a site-specific environmental and social management plan to be prepared in accordance with the parameters laid down in the ESMF and acceptable to the Association, setting forth a set of mitigation, monitoring, and institutional measures to be taken during the implementation and operation of the Project activities to eliminate adverse environmental and social impacts, offset them, or reduce them to acceptable levels, and including the actions needed to implement these measures.

  • Local Mental Health Authority means a county legislative body.

  • Environmental and Social Impact Assessment or “ESIA” means a site-specific report, to be prepared in accordance with the parameters laid down in the ESMF (as hereinafter defined) and acceptable to the Association, identifying and assessing the potential environmental and social impacts of the activities to be undertaken for the Project, evaluating alternatives, and designing appropriate mitigation, management, and monitoring measures.

  • Managed Care Plans means all health maintenance organizations, preferred provider organizations, individual practice associations, competitive medical plans and similar arrangements.

  • Quality Assurance Plan or “QAP” shall have the meaning set forth in Clause 11.2;

  • Unfit-for-use tank system means a tank system that has been determined through an integrity assessment or other inspection to be no longer capable of storing or treating hazardous waste without posing a threat of release of hazardous waste to the environment.

  • Status with regard to public assistance means the condition of being a recipient of federal, state, or local assistance, including medical assistance, or of being a tenant receiving federal, state, or local subsidies, including rental assistance or rent supplements.