Provider Dispute Resolution System Sample Clauses

Provider Dispute Resolution System. The PH-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The resolution of all issues regarding the interpretation of Department-approved Provider Agreements must be handled between the two (2) entities and shall not involve the Department; therefore, these are not within the scope of the Department’s BHA. Additionally, the Department’s BHA or its designee is not an appropriate forum for Provider Disputes/Appeals with the PH-MCO. Prior to implementation, the PH-MCO must submit to the Department, their policies and procedures relating to the resolution of Provider Disputes/Provider Appeals for approval. Any changes made to the Provider Disputes/Provider Appeals policies and procedures must be submitted to the Department for approval prior to implementation of the changes. The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by th e Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO’s Provider Disputes/Provider Appeals policies and procedures must include at a minimum: • Informal and formal processes for settlement of Provider Disputes; • Acceptance and usage of the Department’s definition of Provider Appeals and Provider Disputes; • Timeframes for submission and resolution of Provider Disputes/Provider Appeals; • Processes to ensure equitability for all Providers; • Mechanisms and time-frames for reporting Provider Appeal decisions to PH-MCO administration, QM, Provider Relations and the Department; and • Establishment of a PH-MCO Committee to process formal Provider Disputes/Provider Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Health Care Providers/peers; – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues; – Access to data necessary to assist committee members in making decisions; and – Documentation of meetings and decisions of the Committee.
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Provider Dispute Resolution System. 16.11.6.1 The Contractor shall establish and use a procedure to resolve billing, payment, and other administrative disputes between Providers and the Contractor arising under Provider Contracts including:
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Provider Dispute Resolution System. The Contractor shall develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal settlement of Providers' disputes at the lowest level and a formal process for appeal. The resolution of all issues regarding the interpretation of Department approved provider PH-MCO contracts shall be handled between the two entities and shall not involve the Department. The Department's Bureau of Hearings and Appeals or its designee is not an appropriate forum for dispute decisions with PH-MCO. Prior to implementation, the PH-MCO shall submit to the Department, their policies and procedures relating to the resolution of Provider disputes/appeals for approval. Any changes made to the Provider disputes/appeals policies and procedures shall be submitted to the Department for approval prior to implementation of the changes. The PH-MCO's policies and procedures shall include at a minimum:
Sample 1
Provider Dispute Resolution System. The Contractor must submit to the Department copies of the completed Provider Dispute Resolution System Quarterly and Annual Reports relating to Provider specific disputes and resolutions.
Sample 1

Related to Provider Dispute Resolution System

  • Dispute Resolution Procedures (a) In the event a dispute arises about the interpretation, application, calculation of Loss, or calculation of payments or otherwise with respect to this Single Family Shared-Loss Agreement (“SF Shared-Loss Dispute Item”), then the Receiver and the Assuming Institution shall make every attempt in good faith to resolve such items within sixty (60) days following the receipt of a written description of the SF Shared-Loss Dispute Item, with notification of the possibility of taking the matter to arbitration (the date on which such 60-day period expires, or any extension of such period as the parties hereto may mutually agree to in writing, herein called the “Resolution Deadline Date”). If the Receiver and the Assuming Institution resolve all such items to their mutual satisfaction by the Resolution Deadline Date, then within thirty (30) days following such resolution, any payment due as a result of such resolution shall be made arising from the settlement of the SF Shared-Loss Dispute.

  • Dispute Resolution Process Any claim, dispute or other matter in question not resolved by the process identified in Paragraph

  • Dispute Resolution Procedure 21.1 All disputes or grievances arising between the Parties shall as far as practical be resolved at the workplace level through consultation. Accordingly the following procedure must be followed:

  • Dispute Resolution All or any disputes arising out or touching upon or in relation to the terms and conditions of this Agreement, including the interpretation and validity of the terms thereof and the respective rights and obligations of the Parties, shall be settled amicably by mutual discussion, failing which the same shall be settled through the adjudicating officer appointed under the Act.

  • Alternate Dispute Resolution In the event of any issue of controversy under this Agreement, the PARTIES may pursue Alternate Dispute Resolution procedures to voluntarily resolve those issues. These procedures may include, but are not limited to, conciliation, facilitation, mediation, and fact finding.

  • Third Party Dispute Resolution The Consulting Firm shall (i) consider only the items that are then disputed by the parties, (ii) shall be bound by the terms of the Agreement and (iii) shall only make a determination of such disputed matters in favor of the proposal made by the Purchasers or the Sellers (as may be presented by each party to the Consulting Firm in writing, which shall be shared with the other party) and shall not make an independent proposal. The Consulting Firm shall prepare a written determination of any disputed matters and deliver the determination to the Purchasers and the Sellers within fifteen (15) Business Days after the date the Consulting Firm is engaged. Each party shall cooperate fully with the Consulting Firm, including by using reasonable best efforts to provide the information, data and work papers to the extent permitted by applicable Law, so as to enable the Consulting Firm to make a determination of the disputed items as quickly as practicable. The Corrective Action Plan shall be finalized in accordance with the Consulting Firm’s determination of the disputed matters.

  • Applicable Law; Dispute Resolution i. This Agreement, and all claims, disputes or disagreements arising out of or connected with this Agreement, its validity or any breach thereof, shall be governed by the laws in effect in the State of Texas (excluding conflicts of laws provisions), and to the extent applicable to maritime issues, the maritime laws of the United States (excluding conflict of laws provisions).

  • Dispute Resolutions Parties agree to arbitration of dispute in Houston, Texas, USA.

  • Dispute Resolution; Arbitration This Agreement evidences a transaction involving interstate commerce. Any disputes arising from this Agreement shall be decided by binding arbitration which shall be conducted, at the request of any party, in New York, New York, before one arbitrator designated by the American Arbitration Association (the "AAA"), in accordance with the Commercial Arbitration Rules of the AAA, and to the maximum extent applicable, the United States Arbitration Act (Title 9 of the United States Code). Notwithstanding anything in this Agreement to the contrary, any party may proceed to a court of competent jurisdiction to obtain equitable relief at any time. An arbitrator shall have no authority to award punitive damages or other damages not measured by the prevailing party's actual damages. To the maximum extent practicable, an arbitration proceeding under this Agreement shall be concluded within 180 days of the filing of the dispute with the AAA. This arbitration clause shall survive any termination, amendment, or expiration of the Agreement and if any provision of this arbitration clause is found to be unenforceable, the remaining parts of the arbitration clause shall not be affected and shall remain fully enforceable.

  • Dispute Resolution and Arbitration The following procedures shall be used in the resolution of disputes:

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