Continuation of Benefits Pending Appeal & Reinstatement of Benefits Sample Clauses

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:  The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  The services were ordered by an authorized provider;  The original period covered by the original authorization has not expired; and  The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:  The member withdraws the request;  Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  The time period or service limits of a previously authorized services has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall pay for those services.
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Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:  The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  The services were ordered by an authorized provider;  The original period covered by the original authorization has not expired; and  The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:  The member withdraws the request;  Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten
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Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor must continue the member’s benefits if:
Sample 1Sample 2
Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420(a), 42 CFR 438.420(b)(1) - (5), and 42 CFR 438.402(c)(2)(ii). The Contractor must continue the member’s benefits if: • The member or provider files the request for an appeal within sixty (60) days following the date on the adverse benefit determination notice. • The member or provider files the request for continuation of benefits within ten (10) days of the Contractor mailing the notice or the intended effective date of the proposed adverse benefit determination, whichever is later; • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
Sample 1

Related to Continuation of Benefits Pending Appeal & Reinstatement of Benefits

  • Continuation of Benefits Following the termination of Executive’s employment hereunder, the Executive shall have the right to continue in the Company’s group health insurance plan or other Company benefit program as may be required by COBRA or any other federal or state law or regulation.

  • Termination of Benefits Except as provided in Section 2 above or as may be required by law, Executive’s participation in all employee benefit (pension and welfare) and compensation plans of the Company shall cease as of the Termination Date. Nothing contained herein shall limit or otherwise impair Executive’s right to receive pension or similar benefit payments that are vested as of the Termination Date under any applicable tax-qualified pension or other plans, pursuant to the terms of the applicable plan.

  • Extension of Benefits Upon termination of insurance, whether due to termination of eligibility, or termination of the Contract, an extension of benefits shall be provided for a period of no less than 30 days for completion of a dental procedure that was started before Your coverage ended.

  • Duration of Benefits Eligibility for Income Protection benefits will cease upon the earliest of the following dates:

  • Denial of Benefits Subject to prior notification and consultation, a Party may deny the benefits of this Chapter to: (a) investors of the other Party where the investment is being made by a enterprise that is owned or controlled by persons of a third State and the enterprise has no substantive business activities in the territory of the other Party; or (b) investors of the other Party where the investment is being made by a enterprise that is owned or controlled by persons of the denying Party.

  • Cessation of Benefits An employee shall cease to be eligible for benefits of this Plan at the earliest of the following dates:

  • Retention of Benefits Union leave under the following four (4) sections will be unpaid. The Employer will maintain regular pay and xxxx the Union for the costs of the employee’s salary and benefits. If the Union member is part-time or casual, and the leave is greater than their normal work hours, the Employer will pay the employee for the full length of the leave requested by the Union. The Employer will xxxx the Union for these days as noted above. The Union will pay these invoices within twenty-eight (28) days. Union leave is not unpaid leave for the purposes of Article 22.02 [i.e. such leave will not affect the employee’s benefits, seniority or increment anniversary date].

  • Payment of Benefits Any amounts due under this Agreement shall be paid in one (1) lump sum payment as soon as administratively practicable following the later of: (i) Xx. Xxxxxx'x Termination Date, or (ii) upon Xx. Xxxxxx'x tender of an effective Waiver and Release to the Company in the form of Exhibit A attached hereto and the expiration of any applicable revocation period for such waiver. In the event of a dispute with respect to liability or amount of any benefit due hereunder, an effective Waiver and Release shall be tendered at the time of final resolution of any such dispute when payment is tendered by the Company.

  • Commencement of Benefits (a) Unless the Participant elects otherwise, distribution of benefits will begin no later than the sixtieth day after the close of the Plan Year in which the latest of the following events occurs:

  • Limitation of Benefits (a) Anything in this Agreement to the contrary notwithstanding, in the event it shall be determined that any benefit, payment or distribution by the Company or any of its direct and/or indirect subsidiaries to or for the benefit of Employee (whether paid or payable or distributed or distributable pursuant to the terms of this Agreement or otherwise, but determined without regard to any additional payments required under this Section 18) (such benefits, payments or distributions are hereinafter referred to as “Payments”) would, if paid, be subject to the excise tax imposed by Section 4999 of the Code (the “Excise Tax”), then, prior to the making of any Payments to Employee, a calculation shall be made comparing (i) the net after-tax benefit to Employee of the Payments after payment by Employee of the Excise Tax, to (ii) the net after-tax benefit to Employee if the Payments had been limited to the extent necessary to avoid being subject to the Excise Tax. If the amount calculated under (i) above is less than the amount calculated under (ii) above, then the Payments shall be limited to the extent necessary to avoid being subject to the Excise Tax (the “Reduced Amount”). The reduction of the Payments due hereunder, if applicable, shall be made by first reducing cash Payments and then, to the extent necessary, reducing those Payments having the next highest ratio of Parachute Value to actual present value of such Payments as of the date of the change of control, as determined by the Determination Firm (as defined in Section 18(b) below). For purposes of this Section 18, present value shall be determined in accordance with Section 280G(d)(4) of the Code. For purposes of this Section 18, the “Parachute Value” of a Payment means the present value as of the date of the change of control of the portion of such Payment that constitutes a “parachute payment” under Section 280G(b)(2) of the Code, as determined by the Determination Firm for purposes of determining whether and to what extent the Excise Tax will apply to such Payment.

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