External Independent Medical Review Sample Clauses

External Independent Medical Review. If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service.
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External Independent Medical Review. 1. The Member may request review by a certified independent review organization of an adverse determination if:
External Independent Medical Review 

Related to External Independent Medical Review

  • 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.

  • Quoted Investments External Review With respect to Portfolio Investments (including Cash Equivalents) for which market quotations are readily available, the Borrower shall, not less frequently than once each calendar week, determine the market value of such Portfolio Investments which shall, in each case, be determined in accordance with one of the following methodologies (as selected by the Borrower):

  • Joint Job Evaluation Committee The parties entered into agreement December 17, 1992, to ensure the Joint Gender- Neutral Job Evaluation Plan remains current and operational and to that end endorsed the Joint Gender-Neutral Job Evaluation Maintenance Agreement. The parties agree that a guiding principle for the Committee is that there shall be no discrimination between male and female employees wherein a person of one sex is paid more than a person of the other sex for similar or substantially similar work.

  • Unquoted Investments External Review With respect to Eligible Portfolio Investments for which market quotations are not readily available (“Unquoted Investments”):

  • Evaluation Committee A The Association and the Board agree to establish a standing joint Evaluation Development Committee for the purpose of establishing the procedure and process, including the evaluation instrument, for the evaluation of teachers in the District and to regularly review the effectiveness of the procedure and process, including the evaluation instrument, for the evaluation of teachers in the District.

  • TRANSITION COMMITTEE 8.1.0 A transition committee comprised of the employee representatives and the employer representatives, including the Crown, will be established by January 31, 2016 to address all matters that may arise in the creation of the Trust.

  • Technical Advisory Committee (TAC The goal of this subtask is to create an advisory committee for this Agreement. The TAC should be composed of diverse professionals. The composition will vary depending on interest, availability, and need. TAC members will serve at the CAM’s discretion. The purpose of the TAC is to: • Provide guidance in project direction. The guidance may include scope and methodologies, timing, and coordination with other projects. The guidance may be based on: o Technical area expertise; o Knowledge of market applications; or o Linkages between the agreement work and other past, present, or future projects (both public and private sectors) that TAC members are aware of in a particular area. • Review products and provide recommendations for needed product adjustments, refinements, or enhancements. • Evaluate the tangible benefits of the project to the state of California, and provide recommendations as needed to enhance the benefits. • Provide recommendations regarding information dissemination, market pathways, or commercialization strategies relevant to the project products. The TAC may be composed of qualified professionals spanning the following types of disciplines: • Researchers knowledgeable about the project subject matter; • Members of trades that will apply the results of the project (e.g., designers, engineers, architects, contractors, and trade representatives); • Public interest market transformation implementers; • Product developers relevant to the project; • U.S. Department of Energy research managers, or experts from other federal or state agencies relevant to the project; • Public interest environmental groups; • Utility representatives; • Air district staff; and • Members of relevant technical society committees. The Recipient shall: • Prepare a List of Potential TAC Members that includes the names, companies, physical and electronic addresses, and phone numbers of potential members. The list will be discussed at the Kick-off meeting, and a schedule for recruiting members and holding the first TAC meeting will be developed. • Recruit TAC members. Ensure that each individual understands member obligations and the TAC meeting schedule developed in subtask 1.11. • Prepare a List of TAC Members once all TAC members have committed to serving on the TAC. • Submit Documentation of TAC Member Commitment (such as Letters of Acceptance) from each TAC member. Products: • List of Potential TAC Members • List of TAC Members • Documentation of TAC Member Commitment

  • JOINT LABOR MANAGEMENT COMMITTEE In order to encourage open communication, promote harmonious labor relations, and resolve matters of mutual concern, the parties agree to create a joint labor- management committee. The committee will be governed by the following principles:

  • School Board Review The School Board reserves the right to review any decision issued under Level I or Level II of this procedure provided the School Board or its representative notifies the parties of its intention to review within ten (10) days after the decision has been rendered. In the event the School Board reviews a grievance under this section, the School Board reserves the right to reverse or modify such decision.

  • LABOR MANAGEMENT COMMITTEE 1. A Statewide Labor Management Committee consisting of not more than five (5) members selected by the VSEA from among bargaining units represented by VSEA and not more than five (5) members selected by the State shall meet periodically to discuss a mutually agreed agenda which may include methods of improving labor relations, productivity, safety, and health problems of a continuing nature, or other problems which have an impact on conditions of employment; provided, however, these sessions are not for the purpose of discussing pending grievances or for collective bargaining on any subject.

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