Medical Claims Review Sample Clauses

Medical Claims Review. Should there be a dispute over a medical claim under the County's self-funded health plan, it shall be resolved in the following manner: The Insurance Appeals Committee shall first attempt to resolve disputes, not related to medical necessity, as outlined in County’s self-funded health plan document(s) claims procedures. If the dispute remains unresolved, it shall then be referred to the separate arbitration procedure that has been established under the County's self-funded health plan. The aggrieved employee and the County shall each pay one-half (1/2) of the cost of arbitration.
Sample 1Sample 2Sample 3See All (4)
AutoNDA by SimpleDocs
Medical Claims Review. Xxxxxxxx’s clinicians conduct Medical Claims Review retrospectively through the review of medical records to determine whether the care and services provided and submitted for payment were Medically Necessary. Retrospective review is performed when Keystone receives a claim for payment for services that have already been provided. Claims that require retrospective review include, but are not limited to, claims incurred:  under coverage that does not include the Preauthorization program;  in situations such as an emergency when securing an authorization within required time frames is not practical or possible;  for services that are potentially Investigational or Cosmetic in nature; or  for services that have not complied with Preauthorization requirements. A retrospective review decision is generally issued within thirty (30) calendar days of receiving all necessary information. If a retrospective review finds a procedure not to be Medically Necessary, the Member may be liable for payment to the Provider if the Provider is Nonparticipating.
Sample 1
Medical Claims Review. STEP If an employee objects to the Insurance Company’s disposition of a claim, the objection must be filed in writing and submitted to the Human Resources Manager. STEP The Human Resources Manager will send a copy of the filed objection to the Insurance Administrator. The Administrator will review the matter and reply to the employee through the Human Resources Manager. STEP If the matter is still not resolved, a meeting will be scheduled normally within thirty (30) days, unless extended by mutual agreement, and will include the Insurance Administrator, a Union representative, and a representative of the Insurance Company who will issue a final disposition of the matter. The Union can apply for arbitration if a meeting is not held within the thirty (30)day time period.
Sample 1

Related to Medical Claims Review

  • Claims Review The IRO shall perform the Claims Review annually to cover each of the five Reporting Periods. The IRO shall perform all components of each Claims Review.

  • Claims Review Population A description of the Population subject to the Claims Review.

  • Grievance Committee The Hospital will recognize a Grievance Committee composed of the Chief Xxxxxxx and not more than (as set out in Local Provisions Appendix) employees selected by the Union who have completed their probationary period. A general representative of the Union may be present at any meeting of the Committee. The purpose of the Committee is to deal with complaints or grievances as set out in this Collective Agreement. The Union shall keep the Hospital notified in writing of the names of the members of the Grievance Committee appointed or selected under this Article as well as the effective date of their respective appointments. A Committee member shall suffer no loss of earnings for time spent during their regular scheduled working hours in attending grievance meetings with the Hospital up to, but not including arbitration. The number of employees on the Grievance Committee shall be determined locally.

  • Union Grievance Committee (a) The Employer shall recognize a Union Grievance Committee which consists of:

  • Claims Review Report The IRO shall prepare a Claims Review Report as described in this Appendix for each Claims Review performed. The following information shall be included in the Claims Review Report for each Discovery Sample and Full Sample (if applicable).

  • Joint Remediation Committee If the Sellers (acting reasonably) determine that the Purchasers have committed a Major Default, then, at the election of the Sellers, within three (3) Business Days of the Sellers providing the Purchasers written notice of such determination, the Sellers and the Purchasers shall establish a joint remediation committee of designated executives from the Sellers and the Purchasers (“Joint Remediation Committee”) consisting of three (3) members of each of the Sellers and the Purchasers. The Joint Remediation Committee shall be responsible for overseeing the development of a mutually agreeable plan in accordance with subsection 3 below to either (i) remediate any breaches giving rise to the Major Default to the extent such breaches can be remediated and/or (ii) prevent similar breaches from recurring in the future (clauses (i) and (ii), a “Corrective Action Plan”). Each member of the Joint Remediation Committee shall have sufficient authority on the part of his or her respective party to make decisions relating to matters reviewed by the Joint Remediation Committee, and shall be approved by the other party (such approval not to be unreasonably delayed, conditioned or withheld). The Joint Remediation Committee shall have access to Purchaser Personnel that are primarily responsible for the area of the business relationship (such as information technology, data security or regulatory) where the breaches giving rise to the Major Default arise (such Purchaser Personnel, collectively, the “Subject Matter Experts”). The Sellers and the Purchasers shall cause their respective members on the Joint Remediation Committee to, and the Purchasers shall cause the Subject Matter Experts to, act in good faith in connection with the development of the Corrective Action Plan.

  • Claims and Review Procedure 5.1 For all claims other than disability benefits:

  • Claims Review Methodology a. C laims Review Population. A description of the Population subject to the Quarterly Claims Review.‌

  • Claims and Review Procedures 6.1 For all claims other than Disability benefits:

  • Policy Grievance – Employer Grievance The Employer may institute a grievance alleging a general misinterpretation or violation by the Union or any employee by filing a written grievance with the Bargaining Unit President, with a copy to the Labour Relations Officer within twenty (20) days after the circumstances have occurred. A meeting will be held between the parties within ten (10) days. The Union shall reply within ten (10) days after the meeting, and failing settlement, the matter may be referred to arbitration.

Time is Money Join Law Insider Premium to draft better contracts faster.