Complaint system Sample Clauses
A complaint system clause establishes a formal process for parties to raise and address grievances related to the agreement or the services provided under it. Typically, this clause outlines the steps for submitting a complaint, the timeframe for response, and the method for resolving issues, such as through written notice or designated contact points. Its core function is to ensure that concerns are handled systematically and fairly, providing a clear mechanism for dispute resolution and helping to prevent misunderstandings from escalating.
Complaint system. Every prepaid limited health service organization shall establish and maintain a complaint system providing reasonable procedures for resolving written complaints initiated by enrollees and providers. Nothing herein may be construed to preclude an enrollee or a provider from filing a complaint with the commissioner or as limiting the commissioner's ability to investigate such complaints.
Complaint system. The Contractor’s PIU shall operate a system to receive, investigate and track the status of Fraud, Waste and Abuse complaints from Members, Providers and all other sources which may be made against the Contractor, Providers or Members. The system shall contain the following:
(a) Upon receipt of a complaint or other indication of potential Fraud or Abuse, the Contractor’s PIU shall conduct a preliminary inquiry to determine the validity of the complaint;
(b) The PIU should review background information and MIS data; however, the preliminary inquiry shall not include interviews with the subject concerning the alleged instance of Fraud or Abuse;
(c) If the preliminary inquiry results in a reasonable belief that the complaint does not constitute Fraud or Abuse, the PIU should not refer the case to OIG; however, the PIU shall take whatever remedial actions may be necessary, up to and including administrative recovery of identified overpayments;
(d) If the preliminary inquiry results in a reasonable belief that Fraud or Abuse has occurred, the PIU shall refer the case and all supporting documentation to the OIG, with a copy to the Department;
(e) The OIG will review the referral and attached documentation, make a determination and notify the PIU as to whether the OIG will investigate the case or return it to the PIU for appropriate administrative action;
(f) If, in the process of conducting a preliminary review, the PIU suspects a violation of either criminal Medicaid Fraud statutes or the Federal False Claims Act, the PIU shall immediately notify the OIG with a copy to the Department of their findings and proceed only in accordance with instructions received from the OIG;
(g) If the OIG determines that it will keep a case referred by the PIU, the OIG will conduct a preliminary investigation, gather evidence, write a report and forward information to the Department, the PIU, or, if warranted, to the Attorney General’s Medicaid Fraud Control Unit, for appropriate actions;
(h) If the OIG opens an investigation based on a complaint received from a source other than the Contractor, the OIG will, upon completion of the preliminary investigation, provide a copy of the investigative report to the Department, the PIU, or if warranted, to MFCU, for appropriate actions;
(i) If the OIG investigation results in a referral to the MFCU and/or the U.S. Attorney, the OIG will notify the Department and the PIU of the referral. The Department and the PIU shall only take actions c...
Complaint system. The insured has the right to submit a complaint not related with an adverse determination and a review of a complaint related with an adverse determination in accordance with Law No. 194 of August 25, 2000, Bill of Rights and Responsibilities of the Patient, Law No. 161 of November 1, 2010 to amend Art. 2 and 7 of Law No. 194 of 2000 and in accordance with the Patient Protection and Affordable Care Act 75 Fed. Reg. 43330-43364 (July 23, 2010). In case in which the insured has a complaint or doubt on the benefits of the coverage, he or she may submit a claim by visiting or calling our Customer Service Department or visiting one of our Service Centers located throughout the Island, where the complaint will be carefully taken care of and all the necessary measures will be taken to solve the issue in the most efficient and rapid way possible. There is also a complaint and appeals procedure which warrants the insureds the right to submittal, of efficiently investigating the complaint and the prompt and timely decision of complaints and appeals; as our purpose is that our insureds are satisfied with the service being offered and to achieve that the rights and responsibilities of those involved are respected. In addition, this procedure warrants the confidentiality between the parts. The insured or his or her personal representative (family, friend, counsel), by written consent may submit a claim or complaint. In addition, the following persons or entities may submit a claim or complaint on behalf of the insured: The health service provider through written consent; Persons authorized by court or according to state laws to act on behalf of the insured; A representative assigned by the state on behalf of a deceased insured. Staff of a government agency, like the Office of the Insurance Commissioner, the Office of the Health Ombudsman, House of Representatives, the Senate, Office of the Citizen Ombudsman, and the Office of the Governor. MCS Life will confirm that the person submitting the complaint is the personal representative assigned by the insured by calling the insured or by means of any provided written documentation. If MCS Life cannot confirm representation, a letter will be sent to the insured notifying that his or her case will not be processed until the information has been received.