Appeal of Adverse Determinations. An adverse determination is a determination made by HMO or a utilization review agent physician that health care services provided or proposed to be provided are experimental, investigational or not medically necessary. HMO maintains an internal appeal system that provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination. The appeal of an adverse determination process is not part of the complaint process. You, your designated representative or your physician or provider may initiate an appeal of an adverse determination. When services provided or proposed to be provided are deemed experimental, investigational or not medically necessary, HMO or a utilization review agent will regard the expression of dissatisfaction or disagreement as an appeal of an adverse determination. Within five working days of your appeal request, HMO will send you a letter acknowledging the date of receipt of the appeal and a list of documents you must submit. For oral appeals, we will also send you a one-page appeal form for completion that must be returned to HMO. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialty as typically manages the medical condition, procedure or treatment under review. We have thirty days from your appeal request to provide you written notice of the appeal determination. You will receive a written decision of the appeal that will include dental, medical and contractual reasons for the resolution; clinical basis for the decision; specialization of provider consulted; notice of your right to have an independent review organization review the denial; and TDI’s toll free telephone number and address. Expedited Appeal of Adverse Determination Procedures Investigation and resolution of appeals relating to ongoing emergencies or denials of continued hospital stays are referred directly to an expedited appeal process and will be concluded in accordance with the medical or dental immediacy of the case. In no event will the request for an expedited appeal exceed one business day from the date all information necessary to complete the appeal request is received or three calendar days of the appeal request, whichever is sooner. HMO will provide a review by a board certified physician or provider who has not already reviewed your case and who is of the same or similar specialt...
Appeal of Adverse Determinations. In the event that an employee disagrees with any determination regarding a proposed light duty assignment or the initial or continued eligibility for benefits, he or she shall submit a medical assessment to DOF indicating he or she is not medically able to perform his or her regular or assigned light duties, and the following procedure shall apply:
Appeal of Adverse Determinations. The Parties stipulate and agree that the determination of the materiality of a Modification Application and the ultimate determination of the merits of the Modification Application are both land use decisions for which Developer shall have the right to appeal pursuant to Subsection 10-3-2(F) and (I) of the City’s Land Use Ordinances.
