Formal Appeal Clause Samples

Formal Appeal. This procedure applies to decisions regarding non- urgent Pre-Service Claims and Concurrent Claims as well as for Post-Service Claims.

Formal Appeal. Should Business Associate disagree with the informal appeal decision, Business Associate shall submit, within ten (10) working days after Business Associate’s receipt of the decision of the informal appeal, to the CDCR Deputy Director, Division of Correctional Health Care Services, and a photo copy to the CDCR, Assistant Deputy Director, Office of Business Services, written notification indicating why the informal appeal decision is unacceptable, along with a copy of the original statement of dispute and a copy of CDCR’s response. The CDCR Deputy Director, Division of Correctional Health Care Services, or his/her designee may meet with Business Associate to review the issues within twenty (20) working days of the receipt of Business Associate's notification and shall provide Business Associate with written notification of the decision within forty-five (45) working days from the receipt of the formal appeal. The foregoing dispute process is solely for the purpose of disputes arising from the terms and conditions of this Exhibit. Disputes in relation to the scope of work and other terms and conditions shall be in accordance with any other dispute language set forth in the entire Agreement.

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership number; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department ▇▇ ▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. If the dispute or claim is not resolved to Contractor’s satisfaction by the informal appeal process, Contractor may file with the Associate Director, OBS, and a formal written appeal within thirty (30) calendar days of the date of CDCR’s informal written decision. The formal written appeal shall be addressed as follows: Associate Director Office of Business Services California Department of Corrections and Rehabilitation ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇ ▇-▇ Sacramento, CA 95827 Contractor shall specify in the formal written appeal the issue(s) in dispute, the particular relief or remedy sought, the factual basis for Contractor’s claim or dispute, and Contractor’s legal, technical and/or other authority upon which Contractor bases its claim or dispute. The formal written appeal shall include a written certification signed by a knowledgeable company official under the penalty of perjury according to the laws of the State of California pursuant to California Code of Civil Procedure Section 2015.5 that the dispute, claim, or demand is made in good faith, and that the supporting data are accurate and complete. If an Agreement adjustment is requested, the written certification shall further state under penalty of perjury that the relief requested accurately reflects the Agreement adjustment for which the CDCR is responsible. If Contractor is a corporation, the written certification shall be signed by an officer thereof. If Contractor is a sole proprietorship or partnership, it shall be signed by an owner or full partner. If Contractor is other than a corporation, sole proprietorship or partnership, it shall be signed by a principal of the company with authority to bind the company. The Associate Director, OBS, shall issue a formal written decision on behalf of CDCR within thirty (30) calendar days of receipt of the properly addressed formal written appeal. If mutually agreed by the parties, the date for the issuance of CDCR’s final written decision may be extended.

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;  The Member’s HPN membership number ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ HPN will investigate the 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 Formal Appeal. This period may be extended one (1) time by HPN for up to fifteen

Formal Appeal. If the dispute or claim is not resolved to CONTRACTOR’s satisfaction by the informal appeal process, CONTRACTOR may file with the Associate Director, Procurement and Contracts Branch (PCB), OBS, a formal written appeal within thirty (30) calendar days of the date of CDCR’s informal written decision. The formal written appeal shall be addressed as follows: Procurement and Contracts Branch Office of Business Services California Department of Corrections and Rehabilitation ▇.▇. ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇ CONTRACTOR shall specify in the formal written appeal the issue(s) in dispute, the particular relief or remedy sought, the factual basis for CONTRACTOR’s claim or dispute, and CONTRACTOR’s legal, technical and/or other authority upon which CONTRACTOR bases its claim or dispute. The formal written appeal shall include a written certification signed by a knowledgeable company official under the penalty of perjury according to the laws of the State of California pursuant to California Code of Civil Procedure Section 2015.5 that the dispute, claim, or demand is made in good faith, and that the supporting data are accurate and complete. If an Agreement adjustment is requested, the written certification shall further state under penalty of perjury that the relief requested accurately reflects the Agreement adjustment for which the CDCR is responsible. If CONTRACTOR is a corporation, the written certification shall be signed by an officer thereof. If CONTRACTOR is a sole proprietorship or partnership, it shall be signed by an owner or full partner. If CONTRACTOR is other than a corporation, sole proprietorship or partnership, it shall be signed by a principal of the company with authority to bind the company. The Associate Director, PCB, OBS, shall issue a formal written decision on behalf of CDCR within thirty (30) calendar days of receipt of the properly addressed formal written appeal. If mutually agreed by the parties, the date for the issuance of CDCR’s final written decision may be extended.

Formal Appeal. A formal appeal panel will be convened only where it has not been possible to resolve the disagreement using the mediation process. A formal appeal will be heard by a panel under the procedure set out below.

Formal Appeal. Step 3 A. If the grievant is not satisfied with the decision rendered pursuant to Step 2, the decision may be further appealed as follows: 1. If the grievance alleges a violation of a section of the MOU listed under Section 6.13, the grievance may be appealed to mini-arb under the rules and procedures specified in Section 6.13. This mini-arb shall be the only and final level of review for all such grievances. 2. If the grievance alleges a violation of any other section of the MOU which may be appealed beyond the second level, the grievance may be appealed to CDCR/CCHCS Department Director or Designee as follows: a. Within thirty (30) calendar days of the receipt of the second level response, the grievant or CCPOA may appeal the decision to the Director of the Department or designee. b. Within thirty (30) calendar days after receipt of the appealed grievance, the person designated as third level of appeal shall respond in writing to the grievance, subject to the provisions of Sections 6.03 and 6.04. c. This shall be the final level of review for all Health and Safety grievances, any grievances involving the content of an LOI/WID, and “policy” grievances in that they do not involve the interpretation, application or enforcement of the provisions of this MOU. d. Regardless of who files the grievance, a copy of the grievance and said response shall be mailed by the Appointing Authority or designee to the appropriate office of CCPOA. e. If the grievance alleges a violation of the following MOU Sections: 2.03, 2.04, 2.08, 2.09, 5.03, 7.04, 7.05, 7.06, 7.07, 9.03, 9.06, 9.09 (except G. and L.), 10.02 (except D.), 10.07, 10.08, 10.16, 10.19, 11.02, 11.05, 12.04 (except G.), 14.05, 16.02, 16.06, 17.05, 17.06, 17.08, 17.09, 17.11, 18.01,19.01, 19.02, 19.03, 19.06, 19.09, 19.15, 19.16, 20.01, 20.02, 20.06 (except E.), 20.08, 21.01, 21.02, 22.01, 22.03 (except F.), 24.01, 24.03, 24.09, 25.01, 25.02, the grievance may be appealed directly to arbitration after the third level response. The appeal to arbitration shall be made by sending a request for arbitration to the Director of the CalHR, or designee, within thirty (30) calendar days of the third level response. The arbitration shall be conducted in accordance with Section 6.11 of this article. f. If sections of this MOU subject to arbitration after the third level and after the fourth level are appealed in the same grievance, the grievance shall be subject to arbitration after the fourth level response. Time frames f...

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information: • The Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number; • The Member’s HPN membership number ; and • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department ▇.▇. ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ HPN will investigate the 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 Formal Appeal. This period may be extended one (1) time by HPN for up to fifteen (15) days, provided that the extension is necessary due to matters beyond the control of HPN and HPN notifies the Member prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which HPN expects to render a decision. If the extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Member shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If the Formal Appeal results in an Adverse Benefit Determination, the Member will be informed in writing of the following: • The specific reason or reasons for upholding the Adverse Benefit Determination; • Reference to the specific Plan provisions on which the determination is based; • A statement that the Member is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Membe...