Expedited External Review of a Final Internal Adverse Benefit Determination Sample Clauses

Expedited External Review of a Final Internal Adverse Benefit Determination. The Member may request an expedited external review of an Adverse Benefit Determination as well as from a Final Internal Adverse Benefit Determination if the Member’s condition involves a medical condition for which the timeframe for completion of a standard review would seriously jeopardize the Member’s life or health or would jeopardize the Member’s ability to regain maximum function. Further a Member is entitled to an expedited review if the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay or health care service for which the Member received Emergency Services but has not been discharged from a facility. Upon receipt of a request for a qualified expedited external review, the HMO will assign an IRO and will transmit the file to the assigned IRO to review the appeal. The IRO will issue a decision as expeditiously as possible, but in no event later than seventy-two (72) hours of receipt of the request.
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Expedited External Review of a Final Internal Adverse Benefit Determination. The Member may request an expedited external review of an Adverse Benefit Determination as well as from a Final Internal Adverse Benefit Determination if the Member’s condition involves a medical condition for which the timeframe for completion of a standard review would seriously jeopardize the Member’s life or health or would jeopardize the Member’s ability to regain maximum function. Further a Member is entitled to an expedited review if the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay or health care service for which the Member received Emergency Services but has not been discharged from a facility. Upon receipt of a request for a qualified expedited external review, the HMO will assign an IRO and will transmit the file to the assigned IRO to review the appeal. The IRO will issue a decision as expeditiously as possible, but in no event later than seventy-two (72) hours of receipt of the request. SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS‌ Our HMO reimbursement programs for health care Providers are intended to encourage the provision of quality, cost-effective care for our Members. Set forth below is a general description of our HMO reimbursement programs. Please note that these programs may change from time to time, and the arrangements with particular providers may be modified as new contracts are negotiated. If after reading this material you have any questions about how your health care provider is compensated, please contact Keystone at the telephone number provided on your ID card. PROFESSIONAL PROVIDERS‌ Primary Care Physicians Most Primary Care Providers (PCPs) are paid in advance for their services, receiving a set dollar amount per Member, per month for each Member selecting that PCP. This is called a capitation payment and it covers most of the care delivered by the PCP. Covered Services not included under capitation are paid fee-for-service according to the current HMO fee schedule. Capitated PCPs, are also eligible to receive additional payments for meeting certain medical quality, patient service and other performance standards. Referred Specialists Most Referred Specialists are paid on a fee-for-service basis, meaning that payment is made according to our current HMO fee schedule for the specific medical services that the Referred Specialist performs. Obstetricians are paid global fees that cover most of their professional services for prenatal care and...
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Expedited External Review of a Final Internal Adverse Benefit Determination. The Member may request external review of a Final Internal Adverse Benefit Determination by calling OPM at: Toll Free; 0-000-000-0000 The Member may request an expedited external review of the Final Internal Adverse Benefit Determination if the Member’s condition qualifies for an expedited appeal process as described in the Expedited Internal Review of an Adverse Benefit Determination process above. Further a Member is entitled to an expedited review if the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay or health care service for which the Member received Emergency Services but has not been discharged from a facility. Upon receipt of a request for a qualified expedited external review, OPM or an assigned IRO will issue an expedited decision within seventy-two (72) hours of receipt of the request.
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Related to Expedited External Review of a Final Internal Adverse Benefit Determination

  • 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.

  • External Review In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact XxXxx’s Member Engagement Center.

  • Internal Investigations (A) The parties recognize that Florida Highway Patrol personnel occupy a special place in American society. Therefore, it is understood that the state has the right to expect that a professional standard of conduct be adhered to by all Florida Highway Patrol personnel regardless of rank or assignment. Since internal investigations may be undertaken to inquire into complaints of Florida Highway Patrol misconduct, the state reserves the right to conduct such investigations to uncover the facts in each case, but expressly agrees to carefully guard and protect the rights and dignity of accused personnel. In the course of an internal investigation, the investigative methods employed will be consistent with the law (including but not limited to section 112.532, Florida Statutes) and this agreement; nothing in this agreement, however, shall be deemed to diminish the rights of employees under applicable law.

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • HHS Single Audit Unit will notify Grantee to complete the Single Audit Determination Form If Grantee fails to complete the form within thirty (30) calendar days after receipt of notice, Grantee maybe subject to sanctions and remedies for non-compliance.

  • How to Request an External Appeal If you remain dissatisfied with our medical appeal determination, you may request an external review by an outside review agency. In accordance with §27-18.9-8, your external appeal will be reviewed by one of the external independent review organizations (IRO) approved by the Office of the Health Insurance Commissioner. The IRO is selected using a rotational method. Your claim does not have to meet a minimum dollar threshold in order for you to be able to request an external appeal. To request an external appeal, submit a written request to us within four (4) months of your receipt of the medical appeal denial letter. We will forward your request to the outside review agency within five (5) business days, unless it is an urgent appeal, and then we will send it within two (2) business days. We may charge you a filing fee up to $25.00 per external appeal, not to exceed $75.00 per plan year. We will refund you if the denial is reversed and will waive the fee if it imposes an undue hardship for you. Upon receipt of the information, the outside review agency will notify you of its determination within ten (10) calendar days, unless it is an urgent appeal, and then you will be notified within seventy-two (72) hours. The determination by the outside review agency is binding on us. Filing an external appeal is voluntary. You may choose to participate in this level of appeal or you may file suit in an appropriate court of law (see Legal Action, below). Once a member or provider receives a decision at one of the several levels of appeals noted above, (reconsideration, appeal, external), the member or provider may not ask for an appeal at the same level again, unless additional information that could affect such decisions can be provided.

  • Determination by Independent Firm In the event of any question arising with respect to the adjustments provided for in this Article 4 such question shall be conclusively determined by an independent firm of chartered accountants other than the Auditors, who shall have access to all necessary records of the Corporation, and such determination shall be binding upon the Corporation, the Warrant Agent, all holders and all other persons interested therein.

  • 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:

  • Reviewing your bill (a) If you disagree with the amount you have been charged, you can ask us to review your bill in accordance with our standard complaints and dispute resolution procedures.

  • AUDIT REVIEW PROCEDURES A. Any dispute concerning a question of fact arising under an interim or post audit of this AGREEMENT that is not disposed of by AGREEMENT, shall be reviewed by LOCAL AGENCY’S Chief Financial Officer.

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