Direct audits Clause Samples
A direct audits clause grants one party the right to examine and review the records, operations, or facilities of the other party to ensure compliance with the terms of the agreement. Typically, this clause outlines the scope of the audit, the notice period required before an audit can take place, and any limitations on frequency or confidentiality. For example, a company may use this clause to verify that a supplier is adhering to agreed-upon quality standards or financial practices. The core function of this clause is to provide transparency and accountability, helping to prevent fraud, mismanagement, or breaches of contract.
Direct audits. In addition to the audit of the audits undertaken by the Insurer referred in Clause 23.3.1.a, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include:
(i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected or partially settled by the Insurer to assure itself of the legitimacy of the Insurer’s decisions. Claims settlement decisions of the Insurer that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive): Evidence of rigorous review of claims adjudication. Comprehensiveness of claims submissions (documentation) by the EHCPs. Number of type of queries raised by the Insurer during review of claims – appropriateness of queries. Accuracy of claims settlement.
Direct audits. In addition to the audit of the audits undertaken by the ISA referred in Clause 23.3.1.a, the NHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include:
Direct audits. In addition to the audit of the audits undertaken by the ISA referred in Schedule 12, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include:
(i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive): • Evidence of rigorous review of claims adjudication. • Comprehensiveness of claims submissions (documentation) by the EHCPs. • Number of type of queries raised by the ISA during review of claims – appropriateness of queries. • Accuracy of claims settlement.