Appeals of Adverse Benefit Determinations Sample Clauses

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal Type of Claim Level One Appeal HMO Response Time from Receipt of Appeal Level Two Appeal HMO Response Time from Receipt of Appeal Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 24 hours Review provided by HMO personnel not involved in making the adverse benefit determination. Within 24 hours Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care.
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Appeals of Adverse Benefit Determinations. The covered person may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan provides for one level or two levels (Level Two only applies to dental, vision and hearing claims) of appeal. A final adverse benefit determination notice may also provide an option to request an External Review (if available). An appeal of an adverse benefit determination will be evaluated and reviewed by a clinical peer, not involved in the original determination. A clinical peer is: • A physician or other health care professional who holds a non-restricted license in a state of the US and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. • For urgent care reviews concerning child or adolescent substance use disorder or mental disorder, holds a national board certification in child and adolescent psychiatry or a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use and mental disorder as applicable. • For urgent care reviews concerning adult substance use or mental disorder, holds a national board certification in psychiatry, or a doctoral level psychology degree with training and clinical experience in the treatment of adult substance use and mental disorders, as applicable. The covered person has 180 calendar days with respect to Health Claims following the receipt of notice of an adverse benefit determination to request their Level One appeal. The covered person’s appeal must be submitted in writing and must include: • The covered person’s name. • The Policyholder's name. • A copy of Aetna’s notice of an adverse benefit determination. • The covered person’s reasons for making the appeal. • Any other information the covered person would like to have considered. The covered person can send their written appeal to Member Services at the address shown on their ID Card. The covered person may also choose to have another person (an authorized representative) make the appeal on their behalf. The covered person must provide written consent to Aetna. The covered person may be allowed to provide evidence or testimony during the appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services.
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Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two stages of Appeal of the adverse benefit determination. The Member must complete the two stages of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second stage, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims.
Sample 1
Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination (including Coverage Decisions and Disputed Health Care Service decisions) from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing or by phone within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The following chart summarizes some information about how the Appeals are handled for different types of claims.
Sample 1
Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice, or after the notification of a benefit denied due to a contractual exclusion except a request for a Level One Appeal of an Urgent Care claim may also be oral. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an Urgent Care claim or a pre-service claim, a Physician may represent the Member in the Appeal. A Member may be allowed to provide evidence or testimony during the Appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. The HMO provides for two level(s) of Appeal of the adverse benefit determination. The First Level Appeal shall be evaluated by a Physician who shall consult with an appropriate clinical peer or peers, unless the reviewing Physician is a clinical peer. The Physician and clinical peers shall not have been involved in the initial adverse benefit determination. A person who was previously involved with the denial may answer questions. All written denials of requests for Covered Benefits on the ground that such benefits are not Medically Necessary, appropriate, effective, or efficient shall be signed by a licensed Physician familiar with standards of care in Colorado. If the HMO upholds an adverse benefit determination at the first level of Appeal, and the reason for the adverse determination was based on Medical Necessity, or Experimental or Investigational reasons, or a contractual exclusion and the Member presents evidence for a medical professional that there is a reasonable medical basis that the exclusion does not apply to the denied benefit, the Member or his/her authorized representative have the right to pursue an Appeal to an independent utilization review organization (IURO), or file the voluntary Level Two Appeal. The Member must complete all steps in the HMO Appeals process before bringing a lawsuit against the HMO. A final adverse benefit determination notice will provide an option to request an External Rev...
Sample 1
Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made either orally or in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf. In addition, in case of an urgent care claim or a pre-service claim, a Physician may also represent the Member in the Appeal. The HMO provides for one level of Appeal of the adverse benefit determination. The Member must complete that level of HMO review before bringing a lawsuit against the HMO. The following chart summarizes some information about how the Appeal is handled for different types of claims. The Appeal shall be conducted by a Physician who did not participate in the Utilization Review or adverse benefit determination at issue. However, in the case of an Appeal involving a medical or surgical specialty or subspecialty, HMO shall, upon request by a Member or their representative, utilize a board eligible or certified Physician in the appropriate specialty or subspecialty area to conduct the Appeal.
Sample 1
Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal.
Sample 1
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Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 2 years from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice to the following address. The following chart summarizes some information about how the Appeals are handled for different types of claims. Name: Aetna Health Inc. Title: Regional Medical Service Complaint and Appeals Unit Address: P.O. Box 10169, Van Nuys, CA 91410 Phone: 000-000-0000 Fax: 000-000-0000 HMO Timeframe for Responding to an Adverse Benefit Determination Appeal Type of Claim Level One Appeal HMO Response Time from Receipt of Appeal Level Two Appeal HMO Response Time from Receipt of Appeal Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care.
Sample 1
Appeals of Adverse Benefit Determinations. You may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan provides for two levels of appeal. It will also provide an option to request an external review of the adverse benefit determination. You have 180 calendar days following the receipt of notice of an adverse benefit determination to request your level one appeal. Your appeal may be submitted verbally or in writing and should include:  Your name;  Your employer’s name;  A copy of Aetna’s notice of an adverse benefit determination;  Your reasons for making the appeal; and  Any other information you would like to have considered. The notice of an adverse benefit determination will include the address where the appeal can be sent. If your appeal is of an urgent nature, you may call Aetna’s Customer Service Unit at the toll-free phone number on your ID card. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing verbal or written consent to Aetna. Level One Appeal - Group Health Claims A level one appeal of an adverse benefit determination shall be provided by Aetna personnel not involved in making the adverse benefit determination. Urgent Care Claims (May Include concurrent care claim reduction or termination) Aetna shall issue a decision within 36 hours of receipt of the request for an appeal. Pre-Service Claims (May Include concurrent care claim reduction or termination) Aetna shall issue a decision within 15 calendar days of receipt of the request for an appeal.
Sample 1

Related to Appeals of Adverse Benefit Determinations

  • Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to an ICT technical, financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the President of the British Computer Society (or any other association that has replaced the British Computer Society). The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure by either Party to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his/her appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • Certain Determinations For purposes of determining whether and the extent to which the Total Payments will be subject to the Excise Tax: (i) no portion of the Total Payments the receipt or enjoyment of which the Executive shall have waived at such time and in such manner as not to constitute a “payment” within the meaning of Section 280G(b) of the Code will be taken into account; (ii) no portion of the Total Payments will be taken into account which, in the opinion of tax counsel (“Tax Counsel”) reasonably acceptable to the Executive and selected by the Accounting Firm, does not constitute a “parachute payment” within the meaning of Section 280G(b)(2) of the Code (including by reason of Section 280G(b)(4)(A) of the Code) and, in calculating the Excise Tax, no portion of such Total Payments will be taken into account which, in the opinion of Tax Counsel, constitutes reasonable compensation for services actually rendered, within the meaning of Section 280G(b)(4)(B) of the Code, in excess of the “base amount” (as set forth in Section 280G(b)(3) of the Code) that is allocable to such reasonable compensation; and (iii) the value of any non-cash benefit or any deferred payment or benefit included in the Total Payments will be determined by the Accounting Firm in accordance with the principles of Sections 280G(d)(3) and (4) of the Code. The Executive and the Company shall furnish such documentation and documents as may be necessary for the Accounting Firm to perform the requisite calculations and analysis under this Section 6 (and shall cooperate to the extent necessary for any of the determinations in this Section 6(c) to be made), and the Accounting Firm shall provide a written report of its determinations hereunder, including detailed supporting calculations. If the Accounting Firm determines that aggregate Total Payments should be reduced as described above, it shall promptly notify the Executive and the Company to that effect. In the absence of manifest error, all determinations by the Accounting Firm under this Section 6 shall be binding on the Executive and the Company and shall be made as soon as reasonably practicable and in no event later than 15 days following the later of the Executive’s date of termination of employment or the date of the transaction which causes the application of Section 280G of the Code. The Company shall bear all costs, fees and expenses of the Accounting Firm and any legal counsel retained by the Accounting Firm.

  • Procedures and Presumptions for Determination of Entitlement to Indemnification It is the intent of this Agreement to secure for Indemnitee rights of indemnity that are as favorable as may be permitted under the DGCL and public policy of the State of Delaware. Accordingly, the parties agree that the following procedures and presumptions shall apply in the event of any question as to whether Indemnitee is entitled to indemnification under this Agreement:

  • Procedure for Determination of Entitlement to Indemnification (a) To obtain indemnification under this Agreement, Indemnitee shall submit to the Company a written request, including therein or therewith such documentation and information as is reasonably available to Indemnitee and is reasonably necessary to determine whether and to what extent Indemnitee is entitled to indemnification. The Secretary of the Company shall, promptly upon receipt of such a request for indemnification, advise the Board of Directors in writing that Indemnitee has requested indemnification.

  • Indemnification Determinations Indemnification of an Indemnified Person pursuant to Section 8.4 shall be made if (a) the court or body before whom the proceeding is brought determines, in a final decision on the merits, that such Indemnified Person was not liable by reason of Disabling Conduct or (b) in the absence of such a determination, a majority of a quorum of disinterested, non-party Trustees or independent legal counsel in a written opinion make a reasonable determination, based upon a review of the facts, that such Indemnified Person was not liable by reason of Disabling Conduct. In making such a determination, the Board of Trustees of the Trust shall act in conformity with then applicable law and administrative interpretations, and shall afford a Trustee requesting indemnification who is not an “interested person” of the Trust, as defined in Section 2(a)(19) of the 1940 Act, a rebuttable presumption that such Trustee did not engage in disabling conduct while acting in his capacity as a Trustee.

  • Selection of Reviewing Party; Change in Control If there has not been a Change in Control, any Reviewing Party shall be selected by the Board of Directors, and if there has been such a Change in Control (other than a Change in Control which has been approved by a majority of the Company's Board of Directors who were directors immediately prior to such Change in Control), any Reviewing Party with respect to all matters thereafter arising concerning the rights of Indemnitee to indemnification of Expenses under this Agreement or any other agreement or under the Company's Certificate of Incorporation or Bylaws as now or hereafter in effect, or under any other applicable law, if desired by Indemnitee, shall be Independent Legal Counsel selected by Indemnitee and approved by the Company (which approval shall not be unreasonably withheld). Such counsel, among other things, shall render its written opinion to the Company and Indemnitee as to whether and to what extent Indemnitee would be entitled to be indemnified hereunder under applicable law and the Company agrees to abide by such opinion. The Company agrees to pay the reasonable fees of the Independent Legal Counsel referred to above and to indemnify fully such counsel against any and all expenses (including attorneys' fees), claims, liabilities and damages arising out of or relating to this Agreement or its engagement pursuant hereto. Notwithstanding any other provision of this Agreement, the Company shall not be required to pay Expenses of more than one Independent Legal Counsel in connection with all matters concerning a single Indemnitee, and such Independent Legal Counsel shall be the Independent Legal Counsel for any or all other Indemnitees unless (i) the employment of separate counsel by one or more Indemnitees has been previously authorized by the Company in writing, or (ii) an Indemnitee shall have provided to the Company a written statement that such Indemnitee has reasonably concluded that there may be a conflict of interest between such Indemnitee and the other Indemnitees with respect to the matters arising under this Agreement.

  • Indemnitee Rights on Unfavorable Determination; Binding Effect If any Reviewing Party determines that Indemnitee substantively is not entitled to be indemnified hereunder in whole or in part under applicable law, Indemnitee shall have the right to commence litigation seeking an initial determination by the court or challenging any such determination by such Reviewing Party or any aspect thereof, including the legal or factual bases therefor, and, subject to the provisions of Section 15, the Company hereby consents to service of process and to appear in any such proceeding. Absent such litigation, any determination by any Reviewing Party shall be conclusive and binding on the Company and Indemnitee.

  • Determination by Independent Firm In the event of any question arising with respect to the adjustments provided for in this Article 4 such question shall be conclusively determined by an independent firm of chartered accountants other than the Auditors, who shall have access to all necessary records of the Corporation, and such determination shall be binding upon the Corporation, the Warrant Agent, all holders and all other persons interested therein.

  • Determination by the Reviewing Party If the Company reasonably believes that it is not obligated under this Agreement to indemnify the Indemnitee, the Company shall, within 10 days after the Indemnitee’s written request for an advancement or reimbursement of Expenses, notify the Indemnitee that the request for advancement of Expenses or reimbursement of Expenses will be submitted to the Reviewing Party (as hereinafter defined). The Reviewing Party shall make a determination on the request within 30 days after the Indemnitee’s written request for an advancement or reimbursement of Expenses. Notwithstanding anything foregoing to the contrary, in the event the Reviewing Party informs the Company that Indemnitee is not entitled to indemnification in connection with a Proceeding under this Agreement or applicable law, the Company shall be entitled to be reimbursed by Indemnitee for all the Expenses previously advanced or otherwise paid to Indemnitee in connection with such Proceeding; provided, however, that Indemnitee may bring a suit to enforce his/her indemnification right in accordance with Section C.3 below.

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