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.
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. Medical Reconsiderations and Appeals A medical reconsideration or appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: • the service was not medically necessary or appropriate; or • the service was experimental or investigational. You may request an expedited appeal when: • an urgent preauthorization request for healthcare services has been denied; • the circumstances are an emergency; or • you are in an inpatient setting. How to File a Medical Request for Reconsideration You or your physician may file a written or verbal request for reconsideration with our Grievance and Appeals Unit. The request for reconsideration must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is requesting a medical reconsideration on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. You will receive written notification of our determination within: • fifteen (15) calendar days, from the receipt of your request for reconsideration of a prospective or concurrent review; and • fifteen (15) calendar days, from the receipt of your request for reconsideration of a retrospective revie...
Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered dental services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your dentist 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 Blue Cross Dental Customer Service, 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 Blue Cross Dental Customer Service. If you request an administrative appeal, you must do so within one hundred eighty (180) calendar days of receiving a denial of payment for covered dental services. We will acknowledge receipt of your administrative appeal within ten (10) business days. We will conduct a thorough review of your administrative appeal and respond within fifteen (15) calendar days. The letter will provide you with information regarding our determination. Dental Appeals A dental appeal is a request for us to reconsider a full or partial denial of payment for covered dental services because we determined: • the dental service was not dentally necessary or appropriate; • the orthodontic service was not medically necessary; • the service was experimental or investigational. You may request an expedited appeal when the circumstances are an emergency.
Administrative Appeals. If the Service and the taxpayer are unable to resolve an issue by a PFA or an AIR agreement, the taxpayer may pursue an administrative appeal either by requesting an early referral to Appeals under the procedures set forth in Rev. Proc. 99-28, 1999-2 C.B. 109, or by protesting any proposed deficiency related to the issue.
Administrative Appeals. The parties agree that the procedures in Section 9.0 may be modified during the term of this MOU if there is mutual agreement on the modifications. This section is not applicable for matters involving reassignment of a sworn employee from an advanced paygrade position, deselection from a bonus position, or denial of promotion on grounds other than merit. Such matters shall be conducted in conformance with rules and procedures adopted by the Department.
Administrative Appeals. 1. The Vendor has the right to request an administrative appeal as prescribed in 7 CFR 246.18 (Refer to Appendix B of the Vendor Agreement).
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
Administrative Appeals. 1. Within five (5) working days after the decision by the City Manager regarding a formal grievance, an employee may file a written administrative appeal to the Personnel Board with the Human Resources Director. Such written administrative appeal shall, at minimum, contain the following information:
Administrative Appeals. The parties agree that the procedures in Section 9.0 may be modified during the term of this MOU if there is mutual agreement on the modifications.
Administrative Appeals. When administrator appeals are being considered, the District LPDAC will change composition to a majority of administrators according to law.
