Appeals of Eligibility and/or Award Determinations Sample Clauses

Appeals of Eligibility and/or Award Determinations. 5.4.1 Unless otherwise agreed between HOC and the respective Qualified Claimant, or his/her Principal Responsible Attorney, within thirty (30) days following service of any notice of the Claims Processor under Section 5.3 regarding a Claimant’s Eligibility and/or Award Determinations (with the exception of determinations as to deficiencies as set forth in Section 4.5.1), an Enrolled Claimant or his/her Principal Responsible Attorney may appeal the Determination to one (1) of the Special Masters by serving on the Claims Processor a form of appeal (to be agreed upon by the Parties). Within thirty (30) days following (unless otherwise agreed to by the SOC or by application by HOC to the Claims Administrator) receipt of the notice of appeal, and excluding Enhancements claims for lost wages the Claims Processor will review the claim before sending it to one (1) of the Special Masters to determine if the Claims Processor agrees with the appeal. If the Claims Processor agrees with the Settlement Program Claimant’s position, the Claims Processor will issue an amended determination notice, which will then provide the Settlement Program Claimant a new period to consider an appeal. If the Claims Processor does not agree with the Settlement Program Claimant’s position on appeal, such appeal shall be directed to one (1) of the Special Masters. If an Enrolled Claimant or his/her Principal Responsible Attorney does not timely serve an appeal pursuant to this Section 5.4.1, the Claims Processor’s determination is final, binding, and Non-Appealable, absent a decision by HOC to the contrary pursuant to Section 5.1.3.
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Appeals of Eligibility and/or Award Determinations. 4.4.1 Unless otherwise agreed between HOC and the respective Enrolled Claimant or Qualified Claimant, or his/her Principal Responsible Attorney, within thirty (30) days following service of any notice of the Claims Processor under Section 4.3 regarding a Claimant’s Eligibility and/or Award Determinations (with the exception of determinations as to deficiencies as set forth in Section 3.4.1), a Claimant or his/her Principal Responsible Attorney may appeal the Determination to the Special Master by serving on the Claims Processor a form of appeal and an Appeal Deposit of Two Thousand Five Hundred Dollars ($2,500) to be paid by the Principal Responsible Attorney. Under no circumstances will any appeal be reviewed until the Principal Responsible Attorney pays the Appeal Deposit to the Claims Processor in full.
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Related to Appeals of Eligibility and/or Award Determinations

  • Determination of Eligibility The Plan Administrator shall determine the eligibility of each Employee for participation in the Plan based upon information provided by the Employer. Such determination shall be conclusive and binding on all individuals except as otherwise provided herein or by operation of law.

  • Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.

  • 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:

  • Overtime Eligibility and Compensation Employees are eligible for overtime compensation under the following circumstances:

  • Salary Determination 12.5.1 A unit member shall receive a salary not less than the minimum salary nor more than the maximum salary (Articles 12.3 and 12.4) for the rank to which appointed, except as provided in Articles 4.15, 5.6, 10.6.1 or Article 10.6.1.1. The effective dates for salaries shall be the appropriate dates specified in Article 12.2.2.

  • REQUIREMENT ON ELIGIBILITY AND REGISTRATION OF E-BIDDERS 1.1. Any interested party who intend to participate in the online public auction ("E-Bidders") auction can register as a user by logging onto PAH Website

  • Certification of eligibility a. By entering into this contract, the contractor certifies that neither it (nor he or she) nor any person or firm who has an interest in the contractor's firm is a person or firm ineligible to be awarded Government contracts by virtue of section 3(a) of the Xxxxx-Xxxxx Act or 29 CFR 5.12(a)(1).

  • SALARY DETERMINATION FOR EMPLOYEES IN ADULT EDUCATION PCA Article B.3 does not apply in School District No. 34 (Abbotsford).

  • Adverse Benefit Determination An adverse benefit determination is any of the following:  Denial of a benefit (in whole or part),  Reduction of a benefit,  Termination of a benefit,  Failure to provide or make a payment (in whole or in part) for a benefit, and  Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.

  • Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:

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