Risk Adjustment Appeals Sample Clauses

Risk Adjustment Appeals. The MCO may appeal the STATE’s calculation of the MCO’s risk scores upon notification that risk scores will change. Any appeal of risk scores must be filed with the STATE within six weeks of notification of the risk scores. The basis for any appeal by the MCO under this section shall be limited to whether or not the STATE correctly calculated the MCO’s risk scores based on encounter data submitted in a timely manner as required by section 3.6.1. The risk score appeal must contain a succinct explanation of why the MCO finds the scores incorrect, with supporting data sufficient to allow the STATE to evaluate the appeal in a timely fashion.
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Risk Adjustment Appeals. The MCO may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two weeks of notification of the new risk factors. The basis for any appeal by the MCO under this section shall be limited to whether or not the STATE correctly calculated the MCO’S risk factor based on encounter data submitted in a timely manner.‌
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Risk Adjustment Appeals. The MCO may appeal risk factors to the STATE. Any appeal of risk factors must be filed with the STATE within six weeks of notification of the new risk factors. The basis for any appeal by the MCO under this section shall be limited to whether or not the STATE correctly calculated the MCO’s risk factor based on encounter data submitted in a timely manner. The risk score appeal must contain a succinct explanation of why the MCO finds the scores incorrect, with supporting data sufficient to allow the STATE to evaluate the appeal in a timely fashion. If the MCO appeals under this section, the STATE shall continue to pay the MCO using the MCO’s risk factor until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’S risk factor, the STATE shall adjust the MCO’s subsequent rates to correct the miscalculation. The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.
Sample 1
Risk Adjustment Appeals. 40 Section 4.2. Capitation Payment Rates. 40 Section 4.3. Premiums and Copayments. 41 Section 4.4. Payment Error in Excess of $500,000. 42 Section 4.4.1. Independent Audit. 42 Section 4.4.2. Mutually Develop Procedures. 43 Section 4.4.3. Two Year Limit to Assert Claim. 43 Section 4.4.4. Payment Offset. 43 Section 4.4.5. Survival. 43 Section 4.4.6. Notice. 43
Sample 1
Risk Adjustment Appeals. The HEALTH PLAN may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two weeks of notification of the new risk factors. The basis for any appeal by the HEALTH PLAN under this Section shall be limited to whether or not the STATE correctly calculated the HEALTH PLAN’s risk factor based on encounter data submitted in a timely manner as required by Section 3.5.1.
Sample 1

Related to Risk Adjustment Appeals

  • Adjustment Plan (A) If the Employer introduces or intends to introduce a measure, policy, practice or change that affects the terms, conditions or security of employment of a significant number of employees by classification to whom the Collective Agreement applies;

  • Adjustment of Grievance The School District and the teacher shall attempt to adjust all grievances which may arise during the course of employment of any teacher within the School District in the following manner:

  • ADJUSTMENT OF COMPLAINTS Standing Committee Can Call in Members for Discussions of Grievances with the Company. (Page 261, 1946 Transcript) It is agreed that the Union Standing Committee may call in any other employee to accompany them in their meetings with Company officials. Exhibit "A"

  • FORCE ADJUSTMENT Section 1. In the event that the Company determines that a surplus exists and a decrease in the work force becomes necessary, the Company will first advise the Union in writing prior to notifying the affected employee(s). The affected employee(s) will be notified not less than thirty (30) calendar days prior to the date the employee(s) is to be laid off. In matters involving the surplus of fifty (50) or more employees at a single location, the Company will provide the employees sixty (60) days advance notice of the surplus.

  • Workforce Adjustment (a) The Parties recognize that workforce adjustment may be necessary due to the elimination of positions resulting from a reduction in the amount of work required to be done by the Commission, reorganization or program termination.

  • ADJUSTMENT OF GRIEVANCES 26.01 Any complaint, disagreement or difference of opinion between the Employer and the Union, or the employees covered by this Agreement, which concerns the interpretation, application, operation or alleged violation of the terms and provisions of this Agreement, shall be considered as a grievance.

  • Adjustment of the Contract Sum shall include profit. No adjustment shall be made to the extent:

  • Price Adjustment Civil works contracts of long duration (more than 18 months) shall contain an appropriate price adjustment clause.

  • Contingent Price Adjustment It is the policy of the State of Oregon that unprocessed timber shall not be exported from lands owned or managed by the STATE or any of its political subdivisions or agencies, in accordance with the terms of current federal law and the Constitution and the laws of the State of Oregon. PURCHASER specifically agrees that Section 1 is a material term of this contract and is part of the consideration offered to STATE in return for STATE's performance. In the event that any federal law or state constitutional provision or law or any provision of this contract concerning export of unprocessed timber is declared invalid by any court or administrative tribunal, PURCHASER agrees to pay to STATE a contingent price in the amount of the difference between the purchase price set forth in this section and the price obtained by PURCHASER for the exported unprocessed timber. The default provisions of OAR 629-032-0000 through 629-032-0070 shall not apply to exported unprocessed timber. In the event that timber made available under this contract is exported in violation of this contract, PURCHASER shall be in material breach of the contract. STATE shall be entitled to cease performance of the contract and recover, in addition to the adjusted price set out above, a further sum estimated to compensate for administrative expense and the economic impact of the violation upon the State and its citizens. In no case shall this additional amount be less than $10,000 per incident.

  • ADJUSTMENT OF DISPUTES 37.01 (1) The Employer and the Union recognize that grievances may arise in each of the following circumstances:

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