Enrollee appeal definition

Enrollee appeal means an enrollee's request for review of a participating plan's coverage or payment determination. In accordance with 42 CFR 438.400, a Medicaid-based appeal is defined as a request for review of an action, as defined in this section. An appeal is an enrollee's challenge to the actions regarding services, benefits, and reimbursement provided by the participating plan, its service providers, or the Department
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Enrollee appeal means an enrollee's request for review of an adverse benefit determination.
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Enrollee appeal means an enrollee's request for review of an action.
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Examples of Enrollee appeal in a sentence

  • This process is not in lieu of filing an Enrollee appeal but is a step that can be used to resolve the adverse determination instead of moving right to the appeal process.

  • MCCMH provides all staff with enrollee rights and protection training including, but not limited to, role specific training on Enrollee appeal rights and processes, from the initial denial at the time of coverage determination through the final adverse determination.

  • A process for LIHP applicants and Enrollee appeal of actions to a State fair hearing.

  • A copy of the CMSP Medical Benefit Hearing Request Form is located online at https://www.cmspcounties.org/pdf_files/forms/CMSP%201175A%20(07.16).pdf.The Governing Board shall have final approval of the contracting provider and CMSP Enrollee appeal process.

  • Aprocess for LIHP applicants and Enrollee appeal of actions to a State fair hearing.

  • Its local groundwater is not enough for socio-economic activities expected in the new urban area.


More Definitions of Enrollee appeal

Enrollee appeal means an enrollee's request for review of a participating plan's coverage or payment determination. In accordance with 42 CFR 438.400, a Medicaid-based appeal is defined as a request for review of an action, as defined in this section. An appeal is an enrollee's challenge to the actions regarding services, benefits, and reimbursement provided by the participating plan, its service providers, or the Department of Medical Assistance Services. Enrollees or providers or other individuals acting on behalf of enrollees and with the enrollee's written consent may appeal adverse decisions to the participating plan and to DMAS (for Medicaid covered services) after the participating plan's internal appeals process is exhausted.
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Related to Enrollee appeal

  • Enrollee means any person entitled to health care services from a carrier.

  • Board of Appeals means the local board of appeals as created by local ordinance.

  • Appeals Board means the commissioners and deputy commissioners of the Workers’ Compensation Appeals Board acting en banc, in panels, or individually.

  • Appeal Board means the State Charter School Appeal

  • Denial means the process of refusing to grant a license after OCCL receives an application. This constitutes refusal of permission to operate.

  • Disenrollment means either voluntary or involuntary termination of a participant from the Independent Choices Program.

  • Appeal means a request for a review of the Floodplain Administrator's interpretation of any provision of this ordinance.

  • Appeal Committee means the appeal committee established by the Council in terms of section 12(3)(a);

  • Managed care plan means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier.

  • Grievance Committee means the Grievance Committee of the Bar.

  • Notice of Appeal means a notice given pursuant to Condition 6.2.

  • Potential Enrollee means a Medical Assistance Recipient who may voluntarily elect to enroll in a given managed care program, but is not yet an Enrollee of an MCO.

  • Appeal Panel means a panel comprised of a chair and two individuals appointed by the Board to consider appeals under Chapter 7.

  • Expedited Appeal means if a Member appeals a decision regarding a denied request for Prior Authorization (Pre-Service Claim) for an Urgent Care Claim, the Member or Member’s Authorized Representative can request an Expedited Appeal, either orally or in writing. Decisions regarding an Expedited Appeal are generally made within seventy-two (72) hours from the Plan’s receipt of the request.

  • HMO means any health maintenance organization, managed care organization, any Person doing business as a health maintenance organization or managed care organization, or any Person required to qualify or be licensed as a health maintenance organization or managed care organization under applicable federal or state law (including, without limitation, HMO Regulations).

  • Appeals Committee means a Committee or Tribunal duly appointed by by-law to conduct hearings under this by-law;

  • Permanency hearing means a hearing, conducted with respect to a child who is in foster care, to determine the permanency plan for the child which includes:

  • hard of hearing means person having 60 DB to 70 DB hearing loss in speech frequencies in both ears;

  • psychiatric emergency medical condition means a Mental Disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following:

  • Claimant means a person who believes that he or she is being denied a benefit to which he or she is entitled hereunder.

  • COVID-19 emergency means the emergencies declared in the Declaration of Public Emergency (Mayor's Order 2020-045) together with the Declaration of Public Health Emergency (Mayor's Order 2020-046), declared on March 11, 2020, including any extension of those declared emergencies.

  • Claims Administrator means the firm proposed by Class Counsel and appointed by the Courts to administer the Settlement Amount in accordance with the provisions of this Settlement Agreement and the Distribution Protocol, and any employees of such firm.

  • Medical emergency means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.

  • Disciplinary Committee means any person or committee of persons, or any subcommittee thereof, that is author- ized by a self-regulatory organization to issue disciplinary charges, to con- duct disciplinary proceedings, to settle disciplinary charges, to impose dis- ciplinary sanctions or to hear appeals thereof.

  • Reconsideration means review by the director of an insurer’s Notice of Closure.

  • Court of Appeal means the division of the Supreme Court referred to in section 7(1)(b);