APPLICATION FOR BENEFITS AND APPEALS Sample Clauses
APPLICATION FOR BENEFITS AND APPEALS. 28 ARTICLE VI: GENERAL PROVISIONS 35
Application for Benefits Requests for short-term leaves shall be in writing, upon the appropriate form prescribed and provided by the District, and shall be filed with the unit member's supervisor and the appropriate manager five (5) days in advance of the intended leave (except in emergency situations), unless otherwise stated by the provisions of the specific leave.
Claims for Benefits All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is a Pre-Service or Urgent Care Claim, a Health Professional with knowledge of the Member’s Condition will be permitted to act as the Member’s authorized representative, and will be notified of all approvals on the Member’s behalf.
Eligibility for Benefits 1. Sick Leave Bank benefits are available only when the member personally has a severe medical hardship (catastrophic illness or serious accident). 2. Benefits can be received only after all accumulated sick leave and vacation days have been exhausted. 3. Any member receiving Worker's Compensation or disability benefits shall not be eligible to receive benefits from the Sick Leave Bank. 4. A member who is on leave of absence, suspended, or terminated from the ▇▇▇▇▇▇▇ County Board of Education shall not be eligible for Sick Leave Bank benefits. 5. The form, entitled "Request For Sick Leave Benefits" and physician's statement are required before the SLB Review Committee will consider a request for benefits. The physician's statement shall include a history of the illness, date the illness began, a diagnosis and prognosis, and any other related information. 6. Approval by the Sick Leave Bank Review Committee is required prior to the receiving of benefits. 7. Normal pregnancies, childbirth, childcare, or child adoption shall not be considered as eligible reasons for Sick Leave Bank benefits. 8. A four (4)-member Sick Leave Bank Review Committee, consisting of two (2) members appointed by the President of the Association and two (2) appointed by the Superintendent, shall have the responsibility of receiving requests, verifying the validity of requests and approval or denial of requests. Any approval of a request must have the support of at least three (3) members of the committee Sick Leave Bank Review Committee. The Sick Leave Bank Review Committee shall develop its rules of procedure and shall give wide distribution to said rules upon approval of the President of the Association and the Superintendent.
Denial of Benefits Subject to prior notification and consultation, a Party may deny the benefits of this Chapter to: (a) investors of the other Party where the investment is being made by a enterprise that is owned or controlled by persons of a third State and the enterprise has no substantive business activities in the territory of the other Party; or (b) investors of the other Party where the investment is being made by a enterprise that is owned or controlled by persons of the denying Party.
How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.