Complaint and Administrative Appeal Procedures Clause Samples

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coverage ;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue,  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims or any other documentation that you would like us to review;  the date of incident or service; and  your signature. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Dental Appeals ▇.▇. ▇▇▇ ▇▇▇▇▇ ...
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Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the services were excluded from coverage or because you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements. If your inquiry is not resolved to your satisfaction, you may file a complaint or an administrative appeal. If you wish to file a complaint or administrative appeal, you must do so within one hundred and eighty (180) calendar days from the date of notice of the claim determination. You can do so by calling our Customer Service Department at (▇▇▇) ▇▇▇-▇▇▇▇ or 1-800-639- 2227. The Customer Service Representative will log your call and the nature of the issue and attempt to resolve the problem. You may also file a complaint or administrative appeal in writing. To file a complaint or administrative appeal, you must provide the details of your complaint or administrative appeal and include the following information: • name, address, member ID number; • summary of the complaint or administrative appeal, any previous contact with Blue Cross & Blue Shield of Rhode Island and a brief description of the relief or solution you are seeking; • any additional information such as referral forms, claims or any other documentation that you would like us to review; • the date of incident or service; and • your signature. You can use the member Complaint/Administrative appeal form or you can send us a letter with the information requested above. A Customer Service Representative can provide you with a Complaint/Administrative appeal form upon request. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice that the person has the authority to receive information from us on your behalf. You must sign this notice. Please mail the complaint, administrative appeal, or notice to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ You will receive an acknowledgement letter from us within ten (10) business days of the rece...
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Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because: • the services were excluded from coverage; • we failed to make payment (in whole or part) for a service; • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred); • you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or • other limitation on an otherwise covered benefit.
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Related to Complaint and Administrative Appeal Procedures

  • Appeal Process PROVIDER may appeal any adverse finding by the Contract Compliance Officer as set forth in sec. 25.08(20)(c), D.C. Ords.

  • Appeal Procedures A. Employees may appeal discipline imposed under this LOA through the Dispute Resolution Procedure contained in the Collective Bargaining Agreement (i.e. grievance procedure) or to the Minneapolis Civil Service Commission. B. Concerning disciplinary actions taken pursuant to this drug and alcohol testing LOA, available Civil Service Commission appeal procedures are as follows:

  • Appeal Procedure The Appeal will be deemed an appeal of the entire Arbitration Award. In conducting the Appeal, the Appeal Panel shall conduct a de novo review of all Claims described or otherwise set forth in the Arbitration Notice. Subject to the foregoing and all other provisions of this Paragraph 5, the Appeal Panel shall conduct the Appeal in a manner the Appeal Panel considers appropriate for a fair and expeditious disposition of the Appeal, may hold one or more hearings and permit oral argument, and may review all previous evidence and discovery, together with all briefs, pleadings and other documents filed with the Original Arbitrator (as well as any documents filed with the Appeal Panel pursuant to Paragraph 5.4(a) below). Notwithstanding the foregoing, in connection with the Appeal, the Appeal Panel shall not permit the parties to conduct any additional discovery or raise any new Claims to be arbitrated, shall not permit new witnesses or affidavits, and shall not base any of its findings or determinations on the Original Arbitrator’s findings or the Arbitration Award.

  • COMPLAINT PROCEDURES CONTRACTOR shall maintain and adhere to its written procedures for responding to parent complaints. These procedures shall include annually notifying and providing parents of LEA students with appropriate information (including complaint forms) for the following: (1) Uniform Complaint Procedures pursuant to Title 5 of the California Code of Regulations section 4600 et seq.; (2) Nondiscrimination policy pursuant to Title 5 of the California Code of Regulations section 4960 (a); (3) Sexual Harassment Policy, California Education Code 231.5 (a) (b) (c); (4) Title IX Pupil Grievance Procedure, Title IX 106.8 (a) (d) and 106.9 (a); and (5) Notice of Privacy Practices in compliance with Health Insurance Portability and Accountability Act (HIPAA), if applicable. CONTRACTOR shall include verification of these procedures to the LEA upon request. CONTRACTOR shall immediately notify LEA of any complaints filed against it related to LEA students and provide LEA with all documentation related to the complaints and/or its investigation of complaints, including any and all reports generated as a result of an investigation.

  • COMPLAINT AND GRIEVANCE PROCEDURE 9.01 Where a difference arises between the parties relating to the interpretation, application or administration of this Agreement, including any questions as to whether a matter is arbitrable, or where an allegation is made that this Agreement has been violated or whenever an employee who has completed the required probationary period and has been accepted by the Employer for employment in the permanent service, claims that he/she has been disciplined or discharged without reasonable cause, such difference, allegation or claim being hereinafter referred to as the grievance, the grievance procedure set forth below shall apply. 9.02 The Association shall name, appoint or otherwise select a Grievance Committee of no more than three (3) who shall be members of the Association and shall have reached at least the rank of First Class Fire Fighter and other advisors as deemed necessary at the expense of the Association. The Employer shall recognize and deal with the Grievance committee with respect to any matter or dispute which properly arises from a breach of the Collective Agreement from time to time during its term. This committee shall suffer no loss as a result of their attendance at such grievance meetings, hearings, etc. 9.03 No grievance will be considered where the circumstances giving rise to it occurred or originated more than ten (10) full working days before the submission of the grievance. Step 1 - An employee having a grievance will take the matter up through their Association representative. The President or designate shall contact Fire Management to seek a resolution. Step 2 - If the grievance is not settled within five (5) working days, the Association shall submit the matter in writing to the Fire Chief or designate within five (5) working days of receiving the reply from Step 1. The Fire Chief or designate shall render the written decision to the Association within five (5) working days after receiving the written grievance. In the context of this Article a working day shall be deemed to be Monday to Friday excluding designated holidays. Step 3 - If the reply of the Fire Chief is not acceptable to the Association the grievance may be referred to the Chief Administrative Officer (CAO) or the Director of Human Resources within five (5) working days of the written decision of the Fire Chief. The CAO or the Director of Human Resources, who together with the Fire Chief and any other advisors deemed necessary, shall meet with the Association Representatives within 5 working days to consider the grievance. Within five (5) working days of the aforesaid, the CAO or the Director of Human Resources will render a written reply to the employee and the Association. Step 4 - If no resolve is reached at Step 3, the matter shall be submitted to arbitration. Notice shall be given within 5 business days. The parties agree that, for the purposes of this collective agreement the words of the expedited arbitration provisions of the Labour Relations Act, 1995 as amended (Section 49), will be deemed to have been incorporated into this collective agreement. Accordingly and notwithstanding any other provisions of this article (the grievance/arbitration provisions); either party may refer a grievance to expedited arbitration in accordance with the provisions of Section 49. The parties further agree that neither party will raise any jurisdictional or other objection to the application of Section 49 to a grievance under this collective agreement as it pertains to the right to an expedited arbitration. Either party is entitled however, to raise any objection, with the arbitrator with respect to whether the provisions of Section 49 have been properly utilized in respect of any specific grievance (e.g. objections with respect to time limits etc.). Such an appointment by the Minister of Labour or his or her designate will be determined to be a joint appointment in accordance with Section 53(3) of the Fire Protection and Prevention Act. 9.04 Extensions to the time limits in 9.03 may not be unreasonably withheld. 9.05 The employee in all steps of the grievance procedure shall be confined to the grievance and redress sought as set forth in the written grievance initially filed as provided.