Standard Appeal Process Sample Clauses

Standard Appeal Process. Xxxxx Vision will determine if a Member’s Appeal as either an administrative Appeal or a Medical Appeal. The Member is encouraged to provide Xxxxx Vision with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Determination. We will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his Adverse Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.‌‌‌‌ All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. Box 791 Latham, NY 12110 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations or exclusions. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Appeals. Requests submitted to Xxxxx Vision after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision will investigate the Member’s concerns. If the administrative Appeal is overturned, Xxxxx Vision will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of Our first level Appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of the first level administrative Appeal decision. Requests submitted to...
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Standard Appeal Process. We will determine if a Member’s Appeal is an administrative Appeal or a medical Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an Administrative Appeal and a review by an external Independent Review Organization (IRO) on a Medical Appeal. The Member is encouraged to provide Us with all available information to help Us completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide reasonable access to and copies of all documents, records, and other information relevant to the Adverse Benefit Determination.
Sample 1Sample 2Sample 3See All (4)
Standard Appeal Process. We will distinguish a Member’s Appeal as either an administrative Appeal or a medical Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a medical Appeal. The Member is encouraged to provide Us with all available information to help Us completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in an internal or external review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.
Sample 1Sample 2
Standard Appeal Process. Xxxxx Vision will determine if a Member’s Appeal as either an administrative Appeal or a Medical Appeal. The Member is encouraged to provide Xxxxx Vision with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Determination. We will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his Adverse Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. Box 791 Latham, NY 12110
Sample 1
Standard Appeal Process. We will determine a Member’s Appeal as either an administrative Appeal or a Dental Necessity Appeal. The Member is encouraged to provide UCD with all available information to help completely evaluate the Appeal, such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing. All Appeals including administrative, Dental Necessity and Expedited should be submitted in writing to: United Concordia Dental Appeals Division P.O. Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000
Sample 1
Standard Appeal Process. We will distinguish a Member’s Appeal as either an administrative Appeal or a Dental Necessity Appeal.
Sample 1
Standard Appeal Process. Multiple requests to Appeal the same Claim, service, issue or date of service will not be considered at any level of review. UCD will determine if Your Appeal is an administrative Appeal or a Dental Necessity Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. You are encouraged to provide UCD with all available information to help completely evaluate Your Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. Upon Your request and free of charge, we will provide You reasonable access to and copies of all documents, records, and other information relevant to Adverse Benefit Determination. You have the right to appoint an authorized representative to speak on Your behalf in Your Appeals. An authorized representative is a person to whom You have given written consent to represent You in a review of an Adverse Benefit Determination. The authorized representative may be Your treating Provider, if You appoint the Provider in writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals should be submitted to: United Concordia Dental Appeals Division P.O. Box 69420 Harrisburg, PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or treatment is determined to be experimental or investigational. 40XX1984 R01/22 33 a.
Sample 1
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Standard Appeal Process. We will determine if a Member’s Appeal is an administrative Appeal or a Dental Necessity Appeal. Administrative Appeals Administrative Appeals involve contractual issues other than Dental Necessity denials such as Adverse Benefit Determinations based on the Benefit Plan limitations or exclusions. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Administrative Appeals. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate the Member’s concerns. If the Administrative Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the Administrative Appeal is upheld, UCD will inform the Member of the right to begin the second level Administrative Appeal process. The Administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of the first level appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of the first level Administrative Appeal decision. Requests submitted to UCD after sixty (60) days of the first level Administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will meet and review the second level Administrative Appeals. The committee’s decision is final and binding.‌‌‌ The committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the committee meeting.
Sample 1
Standard Appeal Process. We will determine a Member’s Appeal as either an administrative Appeal or a Dental Necessity Appeal. The Member is encouraged to provide UCD with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing. All Appeals including administrative Appeals, Dental Necessity Appeals and Expedited Appeals should be submitted to: United Concordia Dental Appeals Division X.X. Xxx 00000 Xxxxxxxxxx, XX 00000-0000 0-000-000-0000
Sample 1

Related to Standard Appeal Process

  • Appeal Process PROVIDER may appeal any adverse finding by the Contract Compliance Officer as set forth in sec. 25.08(20)(c), D.C. Ords.

  • Appeal Procedure The Appeal will be deemed an appeal of the entire Arbitration Award. In conducting the Appeal, the Appeal Panel shall conduct a de novo review of all Claims described or otherwise set forth in the Arbitration Notice. Subject to the foregoing and all other provisions of this Paragraph 5, the Appeal Panel shall conduct the Appeal in a manner the Appeal Panel considers appropriate for a fair and expeditious disposition of the Appeal, may hold one or more hearings and permit oral argument, and may review all previous evidence and discovery, together with all briefs, pleadings and other documents filed with the Original Arbitrator (as well as any documents filed with the Appeal Panel pursuant to Paragraph 5.4(a) below). Notwithstanding the foregoing, in connection with the Appeal, the Appeal Panel shall not permit the parties to conduct any additional discovery or raise any new Claims to be arbitrated, shall not permit new witnesses or affidavits, and shall not base any of its findings or determinations on the Original Arbitrator’s findings or the Arbitration Award.

  • Classification Appeal Procedure An employee shall have the right to appeal, through the Union, the classification of the position the employee occupies, or where a point rating plan has been used, the right to appeal the position's level. Classification matters are not grievable under Article 8 of this Agreement. Instead, the following procedures shall be followed.

  • Appeal Procedures A. Employees may appeal discipline imposed under this LOA through the Dispute Resolution Procedure contained in the Collective Bargaining Agreement (i.e. grievance procedure) or to the Minneapolis Civil Service Commission.

  • COMPLAINT PROCEDURES CONTRACTOR shall maintain and adhere to its written procedures for responding to parent complaints. These procedures shall include annually notifying and providing parents of LEA pupils with appropriate information (including complaint forms) for the following: (1) Uniform Complaint Procedures pursuant to Title 5 of the California Code of Regulations section 4600 et seq.; (2) Nondiscrimination policy pursuant to Title 5 of the California Code of Regulations section 4960 (a); (3) Sexual Harassment Policy, California Education Code 231.5 (a) (b) (c); (4) Title IX Pupil Grievance Procedure, Title IX 106.8 (a) (d) and 106.9 (a); and (5) Notice of Privacy Practices in compliance with Health Insurance Portability and Accountability Act (HIPPA). CONTRACTOR shall include verification of these procedures to the LEA.

  • Complaint Procedure If an employee has a complaint, which is not a proper subject for a grievance under the grievance procedure, the employee may discuss it with their immediate supervisor. The employee may submit the complaint in writing. If necessary, the employee may also discuss the complaint with the Director of Staff Relations. The employee may have the assistance of their Alliance representative in presenting the complaint. Complaints shall be answered as soon as reasonably possible, but in no event shall an answer be delayed more than seven (7) business days, unless the time for an answer is extended by mutual agreement. If the employee and the Alliance are dissatisfied with the answer they may request a Special Conference.

  • Referral Procedures (a) For signatory Unions now having a job referral system contained in a Schedule A, the Contractor agrees to comply with such system and it shall be used exclusively by such Contractor, except as modified by this Agreement. Such job referral system will be operated in a nondiscriminatory manner and in full compliance with federal, state, and local laws and regulations which require equal employment opportunities and non-discrimination. All of the foregoing hiring procedures, including related practices affecting apprenticeship, shall be operated so as to consider the goals of the College to encourage employment of College residents and utilization of small local businesses on the Project, and to facilitate the ability of all Contractors to meet their employment needs. The Unions will exert their best efforts to recruit and refer sufficient numbers of skilled craft workers to fulfill the labor requirements of the Contractor, including specific employment obligations to which the Contractor may be legally and/or contractually obligated; and to refer apprentices as requested to develop a larger, skilled workforce. The Unions will work with their affiliated regional and national unions, and jointly with the Community Workforce Coordinator and others designated by the College, to identify and refer competent craft persons as needed for Project Work, and to identify and hire individuals, particularly residents of the College, for entrance into joint labor/management apprenticeship programs, or to participation in other identified programs and procedures to assist individuals in qualifying and becoming eligible for such apprenticeship programs, all maintained to increase the available supply of skilled craft personnel for Project Work and future construction of maintenance work to be undertaken by the College.

  • Customer Service, Dispute Resolution If you have a question about your XOOM charges or service you may contact XOOM directly by calling 0-000-000-0000 Monday – Friday 8 (eight) a.m. to 11 (eleven)p.m.

  • COMPLAINT AND GRIEVANCE PROCEDURE 1. When a member of the bargaining unit has any grievance or complaint, he shall forthwith convey to his immediate superior, orally with or without a member of the Association Executive or in writing, all facts relative to the grievance and/or complaint. The member and the superior shall make every attempt to resolve the problem at this preliminary stage.

  • Change Order Procedure The Agency may at any time request a modification to the Scope of Work using a change order. The following procedures for a change order shall be followed:

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