External Review Process Sample Clauses

The External Review Process clause establishes a formal mechanism for disputes or decisions to be evaluated by an independent third party outside the contracting parties. Typically, this process is triggered when internal resolution efforts fail, and it may involve appointing an external expert, arbitrator, or review panel to assess the issue and provide recommendations or binding decisions. The core function of this clause is to ensure impartiality and fairness in resolving disagreements, thereby reducing bias and increasing confidence in the outcome for all parties involved.
External Review Process. External review in the area of professional recognition for traditionally ranked faculty is allowed in the final tenure review. External review may be initiated by the candidate, the DTC, or the department chair. Reviewers external to the faculty of Western Michigan University shall be appropriate to the tenure candidate's specialty area. By mutual agreement of the candidate and the chair of the DTC, one reviewer may be from Western Michigan University, but external to the department.
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External Review Process. External review in the area of professional recognition for traditionally ranked faculty may be initiated by the candidate, the DPC, or the department chair, for a candidate’s promotion review. Reviewers external to the faculty of Western Michigan University shall be appropriate to the promotion candidate's specialty area. By mutual agreement of the candidate and the chair of the DPC, one reviewer may be from Western Michigan University, but external to the department.
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External Review Process. An external review organization is an independent entity under contract with the State of Minnesota to review health plan appeals. If you or someone acting on your behalf has exhausted, or are deemed under applicable law to have exhausted, PIC’s internal appeals processes as described in the “Internal Appeals Process” section of this contract, you or your authorized representative may file a request for external review, along with your filing fee of $25, as noted below, with the Minnesota Department of Commerce at the address below: External Review Process Minnesota Department of Commerce ▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇ Suite 280 St. ▇▇▇▇, MN 55101-2198 You are deemed to have exhausted PIC’s internal appeals process, if PIC waives the exhaustion requirement, PIC fails to substantially comply with the requirements of this section or you request an expedited external review at the same time you qualify for and request an acute care service appeal. If you want an external review, you must request it within six months after the date of PIC’s denial determination. Cases involving fraudulent marketing and agent misrepresentation are not eligible for external review. External review decisions are binding on PIC, but are not binding on you. The fee for an external review is $25 and the maximum fee you may be charged in one year for external reviews is $75. This fee may be waived due to hardship and will be refunded by the Minnesota Department of Commerce, its contracted external review organization, or its designee if you prevail and PIC’s denial decision is completely reversed. You or someone acting on your behalf may file a complaint with the Commissioner of Commerce at any time. You may reach the Minnesota Department of Commerce at 651.539.1600 within the Twin Cities metropolitan area or by calling ▇.▇▇▇.▇▇▇.▇▇▇▇ from outside the Twin Cities.
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External Review Process. A Member shall have four (4) months from the receipt of notice of the Plan’s decision to appeal the denial resulting from the Internal Appeal Process by requesting external review of the decision. To be eligible for external review, the decision of the Plan to be reviewed must involve: i) a Claim that was denied involving medical judgment, including application of the Plan’s requirements as to medical necessity, appropriateness, health care setting, level of care, effectiveness of a Covered Service or a determination that the treatment is experimental or investigational; or ii) a determination made by the Plan to rescind a Member’s coverage or to deny the enrollment request of an individual due to ineligibility for coverage under this Agreement. In the case of a denied Claim, the request for external review may be filed by either the Member or a health care Provider, with the written consent of the Member in the format required by or acceptable to the Plan. The request for external review should include any reasons, material justification and all reasonably necessary supporting information as part of the external review filing.
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External Review Process. Plan Sponsor and Plan Administrator acknowledge their responsibility to administer an external review process as described under the Patient Protection and Affordable Care Act, the Health Care and Education Reconciliation Act, 29 CFR 2590.715-2719 and the U.S. Department of Labor Technical Release 2010-01 (“Technical Release 2010-01”). Plan Sponsor and Plan Administrator delegate to BCBSNC the authority to contract with appropriate independent review organizations on their behalf to administer an external review process. BCBSNC shall set up an external review process consistent with the terms of this Agreement and the federal laws and regulatory guidance referenced above. BCBSNC is responsible for making the decision to allow or deny a request for external review based on the preliminary review criteria specified in Technical Release 2010-01.
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External Review Process. If a Claimant receives a Final Adverse Benefit Determination under the Plan’s internal Claims and Appeals Procedures, the Claimant may (but does not have to) request that the Claim be reviewed under the Plan’s External Review process. As described in detail below, the External Review process entails a review of the Claim by an independent third-party organization.
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External Review Process. Medical Group may elect to subject certain disputes to an external review process (“External Review Election”) as follows: a. Subject to the provisions of the Provider Manual, Medical Group may elect to subject certain disputes regarding claim payment to the Billing Dispute External Review Process as described therein. The resulting determination with respect to payment of any claims that are the subject of disputes so submitted shall be binding on the parties and not be subject to the other provisions contained herein for dispute resolution. b. Subject to the provisions of the Provider Manual, Medical Group may, if Medical Group is acting on behalf of a Subscriber, elect to subject certain disputes concerning a determination by BCBSTX that a service is not or will not be a Covered Service because it is not Medically Necessary or is experimental or investigational in nature (“Adverse Determination”) to the External Review process described in the Provider Manual. The resulting determination with respect to the appropriateness of such Adverse Determination shall be binding on the parties and not be subject to the other provisions contained herein for dispute resolution.
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External Review Process. Any Member, or any Provider acting on behalf of a Member, with the Member’s consent, who is dissatisfied with the result of the Level One Appeal and Level Two Appeal process above, shall have the right to pursue their appeal to an Independent Utilization Review Organization (IURO) in accordance with the procedures set forth below for Final Internal Adverse Benefit Determinations based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a Covered Benefit. Except as set forth in section C above, the right to an External Review under this section shall be contingent upon the Member’s full compliance with both stages of the HMO Level One and Level Two Appeal processes, except that you and any Provider acting on your behalf with your consent shall be relieved of the carrier’s internal Appeal process and may pursue an Appeal through the Independent Health Care Appeals program if: • A determination on any Appeal regarding Urgent or Emergency Care is not forthcoming from HMO within 72 hours of receipt by HMO or notice (in the manner required under the plan) of the Appeal; • A determination on an initial Appeal, other than one regarding Urgent or Emergency Care, is not forthcoming from HMO within 10 calendar days of the date that HMO received notice (in the manner required under the plan) of the Appeal; or • A determination of a subsequent level of Appeal, other than one regarding Urgent or Emergency Care, is not forthcoming from HMO within 20 business days of the date that HMO received notice (in the manner required under the plan) of the Appeal.
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External Review Process. The Mutual Binding Arbitration portion of the ADR Policy.
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Related to External Review Process

  • External Review In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact ▇▇▇▇▇’s Member Engagement Center.

  • Review Process A/E's Work Product will be reviewed by County under its applicable technical requirements and procedures, as follows:

  • AUDIT REVIEW PROCEDURES A. Any dispute concerning a question of fact arising under an interim or post audit of this Agreement that is not disposed of by agreement, shall be reviewed by the County’s Chief Administrative Officer, or designee. B. Not later than 30 days after issuance of the final audit report, Contractor may request a review by County’s Chief Administrative Officer, or designee of unresolved audit issues. The request for review will be submitted in writing. C. Neither the pendency of a dispute nor its consideration by the County will excuse Contractor from full and timely performance, in accordance with the terms of this Agreement. D. Contractor and subcontractors’ contracts, including cost proposals and indirect cost rates (ICR), are subject to audits or reviews such as, but not limited to, a Contract Audit, an Incurred Cost Audit, an ICR Audit, or a certified public accountant (CPA) ICR Audit Workpaper Review. If selected for audit or review, the Agreement, cost proposal and ICR and related workpapers, if applicable, will be reviewed to verify compliance with 48 CFR, Part 31 and other related laws and regulations. In the instances of a CPA ICR Audit Workpaper Review it is Contractor’s responsibility to ensure federal, state, or local government officials are allowed full access to the CPA’s workpapers including making copies as necessary. The Agreement, cost proposal, and ICR shall be adjusted by Contractor and approved by the County contract manager to conform to the audit or review recommendations. Contractor agrees that individual terms of costs identified in the audit report shall be incorporated into the contract by this reference if directed by the County at its sole discretion. Refusal by Contractor to incorporate audit or review recommendations, or to ensure that the Federal, State, or local governments have access to CPA workpapers, will be considered a breach of Agreement terms and cause for termination of the Agreement and disallowance of prior reimbursed costs. E. Should an Audit Report or any State or County audit determine that Contractor has misspent funds and been overpaid based on the requirements of this Agreement and applicable laws and regulations, County shall demand repayment from Contractor in the amount of such audit findings and withhold any payment otherwise due under this Agreement until Contractor repays such amount. Contractor shall repay County such amount within sixty (60) days of the date of the County's demand for repayment. Should Contractor fail to repay County within sixty (60) days of the date of County's demand for repayment, the County may offset the amount due from Contractor against any amounts that would otherwise be due from the County to Contractor pursuant to this Agreement or any other agreement or source.