Administrative Duties 94 SECTION 12.2 Records.....................................................................97 SECTION 12.3 Additional Information to be Furnished to the Issuer........................97
Administrative Appeals An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements, including providing notification of service, when applicable; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination. A medical reconsideration or appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: • the service was not medically necessary or appropriate; or • the service was experimental or investigational. You may request an expedited appeal when: • an urgent preauthorization request for healthcare services has been denied; • the circumstances are an emergency; or • you are in an inpatient setting. You or your physician may file a written or verbal request for reconsideration with our Grievance and Appeals Unit. The request for reconsideration must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is requesting a medical reconsideration on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. You will receive written notification of our determination within fifteen (15) calendar days from the receipt of your request for reconsideration of a prospective, concurrent, or retrospective review. You may request an appeal if our denial was upheld during the initial reconsideration. Your appeal will be reviewed by a provider in the same or similar specialty as your treating provider. You must submit your request for an appeal within forty-five (45) calendar days of receiving of the reconsideration denial letter. You will receive written notification of our appeal determination following the same timeframes noted in the How to File a Medical Request for Reconsideration section above.
Administration Services When a medical prescription drug is administered by infusion, the administration of the prescription drug may be covered separately from the prescription drug. See Infusion Therapy - Administration Services in the Summary of Medical Benefits for benefit limits and the amount you pay. Prescription drugs that are self-administered are not covered as a medical benefit but may be covered as a pharmacy benefit. Please see Pharmacy Prescription Drugs and Diabetic Equipment or Supplies – Pharmacy Benefits section above for additional information. For some medical prescription drugs, after the first administration, coverage may be limited to certain locations (for example, a designated outpatient or ambulatory service facility, physician’s office, or your home), provided the location is appropriate based on your medical status. For a list of medical prescription drugs that are subject to this Site of Care Program, visit our website. Preauthorization may be required to determine medical necessity as well as appropriate site of care. If we deny your request for preauthorization, or you disagree with our determination for the appropriate site of care, you can submit a medical appeal. See Appeals in Section 5 for information on how to file a medical appeal.
Settlement Administration 5.1. The Settlement Administrator shall, under the supervision of the Court, administer the relief provided by this Settlement Agreement by processing Claim Forms in a rational, responsive, cost effective, and timely manner. The Settlement Administrator shall maintain reasonably detailed records of its activities under this Agreement. The Settlement Administrator shall maintain all such records as are required by applicable law in accordance with its normal business practices and such records will be made available to Class Counsel and Defendant’s Counsel upon request. The Settlement Administrator shall also provide reports and other information to the Court as the Court may require. The Settlement Administrator shall provide Class Counsel and Defendant’s Counsel with information concerning Notice, administration, and implementation of the Settlement Agreement. Should the Court request, the Parties shall submit a timely report to the Court summarizing the work performed by the Settlement Administrator, including a report of all amounts from the Settlement Fund paid to Settlement Class Members on account of Approved Claims. Without limiting the foregoing, the Settlement Administrator shall: 5.1.1. Forward to Defendant’s Counsel, with copies to Class Counsel, all original documents and other materials received in connection with the administration of the Settlement, and all copies thereof, within thirty (30) days after the date on which all Claim Forms have been finally approved or disallowed in accordance with the terms of this Agreement; 5.1.2. Receive requests to be excluded from the Settlement Class and other requests and promptly provide to Class Counsel and Defendant’s Counsel copies thereof. If the Settlement Administrator receives any exclusion forms or other requests after the deadline for the submission of such forms and requests, the Settlement Administrator shall promptly provide copies thereof to Class Counsel and Defendant’s Counsel; 5.1.3. Provide weekly reports to Class Counsel and Defendant’s Counsel, including without limitation, reports regarding the number of Claim Forms received, the number approved by the Settlement Administrator, and the categorization and description of Claim Forms rejected, in whole or in part, by the Settlement Administrator; and 5.1.4. Make available for inspection by Class Counsel or Defendant’s Counsel the Claim Forms received by the Settlement Administrator at any time upon reasonable notice. 5.2. The Settlement Administrator shall be obliged to employ reasonable procedures to screen claims for abuse or fraud and deny Claim Forms where there is evidence of abuse or fraud. The Settlement Administrator will reject any claim that does not comply in any material respect with the instructions on the Claim Form or the terms of Paragraphs 1.2 and/or 1.3, above, or is submitted after the Claims Deadline. Each claimant who submits an invalid Claim Form to the Settlement Administrator must be given a notice of the Claim Form’s deficiency and an opportunity to cure the deficiency within twenty-one (21) days of the date of the notice. The Settlement Administrator may contact any Person who has submitted a Claim Form to obtain additional information necessary to verify the Claim Form. 5.3. Defendant’s Counsel and Class Counsel shall have the right to challenge the acceptance or rejection of a Claim Form submitted by Settlement Class Members and to obtain and review supporting documentation relating to such Claim Form. The Settlement Administrator shall follow any agreed decisions of Class Counsel and Defendant’s Counsel as to the validity of any disputed submitted Claim Form. To the extent Class Counsel and Defendant’s Counsel are not able to agree on the disposition of a challenge, the disputed claim shall be submitted to The ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ of JAMS for binding determination. 5.4. In the exercise of its duties outlined in this Agreement, the Settlement Administrator shall have the right to reasonably request additional information from the Parties or any Settlement Class Member.
Program Administration An activity relating to the general management, oversight and coordination of community development programs. Costs directly related to carrying out eligible activities are not included.