External Medical Review Sample Clauses

External Medical Review. The MCO must offer an external medical review to a provider who is unsatisfied with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity. Denials for lack of medical necessity include but are not limited to: Denials, limitations, reductions, suspensions, or terminations that required clinical documentation or medical record review in making the decision to deny (includes pre-service, concurrent, and retrospective reviews); Denials, limitations, reductions, suspensions, or terminations that involved clinical judgement or medical decision-making (i.e., request was referred to a licensed practitioner for review); and Denials, limitations, reductions, suspensions, or terminations based on not meeting a clinical standard or medical necessity requirement (e.g., InterQual®, MCG®, ASAM, or OAC rule 5160-1-01, including EPSDT criteria). Decisions subject to external medical review include an adverse benefit determination in response to a service authorization request or claim payment denial due to lack of medical necessity. Service authorization requests and claim payments that are denied for reasons other than lack of medical necessity and for which no clinical review was completed by the MCO are not subject to external medical review. The MCO must require the provider to first appeal the decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity using the MCO’s internal provider appeals process as specified in ORC 5160.34(B)(12) or provider claim dispute resolution process before the provider requests external medical review. If after a provider requests an external medical review the MCO and provider disagree that an MCO’s decision is subject to an external medical review, ODM or its designee will determine if an external medical review is available for the provider in accordance with this Agreement. The MCO must allow a provider to request an external medical review if the MCO does not issue its response to the provider’s internal appeal of the MCO’s decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity within the required timeframes specified in ORC 5160.34(B)(12) for services authorizations or within 30 business days for provider claim disputes. The MCO must use the entity identified by ODM to perform the external medical review and must pay for the...
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External Medical Review i. The MCO must offer an external medical review to a provider who is unsatisfied with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity. Services that are denied for reasons other than lack of medical necessity (e.g., the service is not covered by Medicaid) are not subject to external medical review.
Sample 1
External Medical Review. The review process conducted by an ODM-identified, independent, External Medical Review entity that is initiated by a Provider that disagrees with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service for lack of Medical Necessity.
Sample 1
External Medical Review. Provider shall utilize Health Plan’s External Medical Review if and when Provider is dissatisfied with Health Plan decisions to deny, limit, reduce, suspend, or terminate a Covered Service for lack of Medical Necessity. Covered Services denied for reasons other than lack of Medical Necessity are not subject to External Medical Review. (SC App. A.§6.g.i)
Sample 1
External Medical Review i. The OhioRISE Plan must offer an external medical review to a provider who is unsatisfied with the OhioRISE Plan's decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity. Services that are denied for reasons other than lack of medical necessity (e.g., the service is not covered by Medicaid) are not subject to external medical review.
Sample 1

Related to External Medical Review

  • Medical Review Officer The Medical Review Officer (MRO) shall be a licensed physician who has a knowledge of substance abuse disorders and has appropriate medical training to interpret and evaluate an individual’s positive test result together with the employee’s medical history and any other relevant biomedical information.

  • MEDICAL REPORT The Agency/Department Head as a condition of granting sick leave with pay, may require medical evidence of sickness or injury acceptable to the Agency/Department. The acceptable medical evidence must be obtained from a medical practitioner currently treating the employee or the employee’s family member.

  • Monitoring Plan keep up with the objectives from the cadetship practice booklet; taking daily notes as well as learning new information every day; currently reporting to the supervisor. Evaluation plan: the final result should be in accordance with the traineeship’s aims and objectives, achieving an improvement of specialty knowledge and language skills. The level of language competence9 in English that the trainee already has or agrees to acquire by the start of the mobility period is: A1 ☐ A2 ☐ B1 ☐ B2 ☒ C1 ☐ C2 ☐ Native speaker ☐ Table B - Sending Institution Please use only one of the following three boxes: 10 The traineeship is embedded in the curriculum and upon satisfactory completion of the traineeship, the institution undertakes to:Award ……...…ECTS credits (or equivalent)11 Give a grade based on: Traineeship certificate ☒ Final report ☒ Interview ☐ Record the traineeship in the trainee's Transcript of Records and Diploma Supplement (or equivalent). Record the traineeship in the trainee's Europass Mobility Document: Yes ☒ No ☐ The traineeship is voluntary and, upon satisfactory completion of the traineeship, the institution undertakes to: Award ECTS credits (or equivalent): Yes ☐ No ☐ If yes, please indicate the number of credits: …. Give a grade: Yes ☐ No ☐ If yes, please indicate if this will be based on: Traineeship certificate ☐ Final report ☐ Interview ☐ Record the traineeship in the trainee's Transcript of Records: Yes ☐ No ☐ Record the traineeship in the trainee's Diploma Supplement (or equivalent). Record the traineeship in the trainee's Europass Mobility Document: Yes ☐ No ☐ The traineeship is carried out by a recent graduate and, upon satisfactory completion of the traineeship, the institution undertakes to: Award ECTS credits (or equivalent): Yes ☐ No ☐ If yes, please indicate the number of credits: …. Record the traineeship in the trainee's Europass Mobility Document (highly recommended): Yes ☐ No ☐ Accident insurance for the trainee The Sending Institution will provide an accident insurance to the trainee (if not provided by the Receiving Organisation/Enterprise): Yes ☐ No ☒ The accident insurance covers: - accidents during travels made for work purposes: Yes ☐ No ☒ - accidents on the way to work and back from work: Yes ☐ No ☒

  • Medical Reports The following applies to all employees: The Employer agrees to pay the fee for medical reports required by the Employer for Sick Leave or Weekly Indemnity provisions to a maximum of fifty dollars ($50.00).

  • Quality Assurance Program An employee shall be entitled to leave of absence without loss of earnings from her or his regularly scheduled working hours for the purpose of writing examinations required by the College of Nurses of Ontario arising out of the Quality Assurance Program.

  • Monitoring Committee The Monitoring Committee shall be established within six months of the signing of the Memorandum of Understanding. Its role is stipulated in the Regulation, in particular Article 4.4 thereof.

  • Technical Redundancy Where an employee's employment is being terminated by the employer by reason of the sale or transfer of the whole or part of the employer's business, nothing in this Agreement shall require the employer to pay compensation for redundancy to the employee if:

  • 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.

  • Monitoring and Review 5.1 The Council and the BID Company shall set up the Standard Services Review Panel within 28 days from the date of this Agreement the purpose of which shall be to:

  • 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.

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