Standard Appeals Process Clause Samples

Standard Appeals Process. All of the staff at Rocky Mountain PACE share responsibility with you, your family or caregiver in providing you the comprehensive health care services identified in your Plan of Care as authorized by the Interdisciplinary Team. You, your family or caregiver are encouraged to contact a member of the Interdisciplinary Team when you have a disagreement with Rocky Mountain PACE’s non-coverage, reduction in services, or of nonpayment for a service. If we deny your request for a service or for payment of a claim, we will give you a written copy of this information on the appeals process, including a form that you may use to request your appeal. You may also make your appeal known verbally, and PACE staff will document and submit your request for an appeal. The Rocky Mountain PACE Quality Assurance Manager or designee will respond to you in writing within two working days, stating that your appeal has been received. A person not involved in our initial decision to deny your request for a service or to pay a claim will reevaluate your appeal. The reviewer will be an appropriately credentialed and impartial individual who was not involved in the original action and does not have a stake in the outcome of the appeal. You or your authorized representative may present or submit to us relevant facts and/or evidence for review, either in person or in writing for consideration during the appeal process. Within thirty (30) calendar days of receiving the appeal, Rocky Mountain PACE will notify you by certified mail of the appeals decision. A copy of the notification will be kept in your file. Rocky Mountain PACE may not stop or reduce services while your appeal is pending. If the appeal is not resolved in your favor, you may be charged for the cost of the services. Rocky Mountain PACE has an expedited appeal process for situations in which you, or your family or caregiver believe your life, health, or ability to regain maximum function would be seriously jeopardized, absent provision of the service in dispute: • You or your authorized representative may present or submit relevant facts and/or evidence for review, to support your request for an expedited appeal. • The Quality Assurance Department will respond to your request for an expedited appeal within 24 hours and notify you if your appeal has been found to meet the criteria for expediting an appeal. • For expedited appeals you will be notified in writing, in the same manner as described in the standard appeal process,...
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Standard Appeals Process. The standard Appeal process includes the following: 6.4.5.1. Standard Appeals for Actions communicated on a Notice of Action – continued services not requested. 6.4.5.2. An Enrollee who disagrees with a decision or Action communicated on a Notice of Action may file an Appeal orally or in writing. 6.4.5.3. All of the following shall apply: 6.4.5.3.1. The Enrollee shall file the Appeal within 90 calendar days from the date on the Notice of Action. 6.4.5.3.2. The Contractor shall confirm receipt of Appeals in writing within five (5) business days. 6.4.5.3.3. The Contractor shall send the Enrollee a written notice of the resolution within 45 calendar days of receiving the Appeal that includes: • The Contractor’s decision and date of decision; • The reason for the decision; and‌ • The right to request a Fair Hearing if the Enrollee disagrees with the decision. 6.4.5.4. The Contractor may extend the timeframe up to 14 additional calendar days if the Enrollee requests an extension or the Contractor can demonstrate that it needs additional information and that the added time is in the Enrollee’s interest. If the extension is not requested by the Enrollee or the Enrollee’s proxy, the Contractor shall provide a written notice to the Enrollee stating the reason for the extension.
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Standard Appeals Process. 8.4.4. 1 An Enrollee who disagrees with a decision or Action communicated on a Notice of Action may file an Appeal orally or in writing.
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Standard Appeals Process 
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Related to Standard Appeals Process

  • Appeals Process A provider may be denied approval to offer the free entitlements or have their funding withdrawn as set out above. The provider can appeal against that decision.

  • Appeals Procedure If Employee appeals to the Administrator, Employee or his authorized representative may submit in writing whatever issues and comments he believes to be pertinent. The Administrator shall reexamine all facts related to the appeal and make a final determination of whether the denial of benefits is justified under the circumstances. The Administrator shall advise Employee in writing of: (1) The Administrator's decision on appeal. (2) The specific reasons for the decision. (3) The specific provisions of the Agreement on which the decision is based. Notice of the Administrator's decision shall be given within 60 days of the Claimant's written request for review, unless additional time is required due to special circumstances. In no event shall the Administrator render a decision on an appeal later than 120 days after receiving a request for a review.

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • Claims Process We intend to appoint the senior trustee as the authorized representative to take action on behalf of holders of each series of the notes under the guarantee. The authorized representative will agree to make a demand of the FDIC upon our failure to pay interest or principal on any series of the notes when due. As provided in the FDIC’s regulations, a holder will also have the option to elect not to be represented by the authorized representative. Upon our failure to pay interest or principal, the authorized representative and a holder that has elected not to be so represented must follow the FDIC’s required procedures for making a demand under the guarantee. In addition to the procedures described below, the authorized representative will be required when making a demand, to the extent not previously provided in the master agreement, to provide the FDIC with information regarding its authority, including: its financial and organizational capacity to act as representative, its exclusive authority to act on behalf of each noteholder and its fiduciary responsibility to the noteholders when acting as such, as established by the senior indenture, and its authority to make the assignment of each noteholder’s right, title, and interest in the notes to the FDIC. Any demand under the guarantee must be accompanied by a proof of claim, satisfactory in form and content to the FDIC, which includes evidence of the occurrence of a payment default and the claimant’s ownership of the applicable notes. The claimant must provide to the FDIC an assignment, satisfactory in form and content to the FDIC, of the noteholder’s right, title and interest in the notes to the FDIC and the transfer to the FDIC of any claim in any insolvency proceeding against us. The assignment must also grant to the FDIC the right to receive any and all distributions on the note from the proceeds of any bankruptcy. If a holder receives a payment on a note from a bankruptcy, any obligation of the FDIC under the guarantee would be reduced proportionally. Demands must be made by the authorized representative or by a holder that elects not to be represented by the authorized representative within 60 days of the occurrence of the payment default. Upon payment by the FDIC of any amount under the guarantee, the FDIC will be subrogated to the rights of the recipient noteholder against us, including in respect of any insolvency proceeding, to the extent of such payment.

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