Administrative Appeal Hearing
Administrative Appeal Hearing Sample Clauses
Related to Administrative Appeal Hearing
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; 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.
Formal Hearing If after the informal hearing, the University President or designee determines that charges are warranted, he or she shall call for the creation of a Hearing Board of six members.
Hearing Decision The decision of the Board shall be in writing and shall contain findings of fact and the personnel action approved, if any. The findings may reiterate the language of the pleadings or simply refer to them. The decision of the Board shall be certified to the Superintendent or designee who recommended the personnel action, and he/she shall enforce and follow this decision. A copy of the decision shall be delivered to the appellant or his/her designated representative personally or by registered mail. The decision of the Board shall be final.
Appeals Committee An Appeals Committee is hereby established composed of one member appointed by the Union, one member appointed by the Employer or by the Association, as the case may be, and a Public Member appointed by both these members.
Claims Administrator A. The Human Resources Director through his/her designated Claims Administrators shall administer the provision of this policy. The City Physician shall provide the City's Claims Administrators with all available medical information concerning the Employee's injury and/or medical opinions as requested. Medical information and opinions shall be based upon the Employee's medical records and/or physical examination. Questions of Employee eligibility shall be determined by the provisions established under State Statute 49-110, 49-111 and Oklahoma Worker's Compensation Title 85. Prior to any denial of injury leave benefits where lost time actually occurred, the administrator shall notify Union and allow a Union representative the opportunity to review the application pending denial and provide any additional information relating to same as may be necessary. Should the City change designated Claims Administrators Local 176 will be notified in writing.
Board Hearing At the board hearing, evidence may be presented by the administration and the teacher, as to (a) whether a reduction in force is reasonably necessary and is being made in good faith and for the best interests of the District and (b) whether the recommendation to not renew the specific teacher is being made in good faith under this Reduction in Force Agreement.
Claims Administration An employee will be required to comply with any and all rules and regulations and/or limitations established by the carrier or applicable third party administrator and contained in the policy, and employees and their dependents shall look solely to such carrier or third party administration for the adjudication of the payment of any and all benefits claims.
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:
Informal Hearing By mutual agreement, an employee against whom disciplinary action is being recommended may meet with the Superintendent or his/her designee prior to written notification of official charges. The employee shall be informed orally of the reasons for disciplinary action and the action to be taken and be given an opportunity to respond. The employee may be represented at the hearing by a representative of his/her choice.
Pre-Disciplinary Hearing When the COUNTY intends to take disciplinary action involving discharge or suspension, the COUNTY shall notify the non-probationary employee and the UNION in writing of the charges against the employee and the proposed disciplinary action and shall provide the employee with the opportunity to respond to the charges at a hearing with the supervisor or person having authority to impose the proposed disciplinary action. In the event this proceeding is recorded, the COUNTY will provide a copy of the recording and/or transcript to the UNION.
