Claim Appeals Sample Clauses

Claim Appeals. In the event of a claim denial by PBM, PBM shall promptly communicate to the Covered Person the right to appeal according to the Covered Person's Benefit Contract and Pharmacy Rider and applicable law.
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Claim Appeals. As of the Closing Time, OMNOVA shall have sole responsibility for the determination of claim appeals filed by OMNOVA Employees under the OMNOVA Medical Plan. Claim appeals filed by employees of OMNOVA under the GenCorp Medical Plan will be determined by GenCorp under the GenCorp Medical Plan.
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Claim Appeals. Any complaint or grievance regarding the amount of a payment or non-payment hereunder shall be submitted by Participating Provider in writing to QualCare or the applicable Payor within twelve (12) months of the receipt of such payment or receipt of the denial of such payment. If no complaint or grievance has been received by QualCare or the applicable Payor within such twelve (12) month period, the payment or non-payment shall be considered final, and Participating Provider shall forfeit any right to contest such payment or non-payment.
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Claim Appeals. Appeals will be reviewed with a new full and fair review. If the denial reason was due to medical necessity or experimental/investigational rationale, the appeal will be reviewed by a qualified Physician who had no involvement in the initial review or any prior reviews. If, pursuant to such review, the clinical decision is upheld, then the Covered Person may have the right to seek Independent External Review. The decision of the independent review organization (“IRO”) will be final and binding.
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Claim Appeals. (a) In the event that PORI makes only partial payment or denies payment of a Clean Claim, Physician may appeal the decision by sending a letter marked "Appeal Request" to the Accounts Payable Department at PORI. Such letter shall contain the following information: Physician name, date of service, date of billing, date of partial payment or payment denial, and the reason(s) the claim merits consideration. The appeal must be submitted to PORI within sixty (60) days of the date of partial payment or denial. Appeals submitted after the sixty (60) day limit shall be considered null and void.
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Claim Appeals. As of the Effective Date, the REX Xxxical Plan shall have sole responsibility for the determination of claim appeals filed by REX Xxxloyees under the REX Xxxical Plan. Claim appeals filed by employees of REX xxxer the RSI Medical Plan will be determined by the RSI Medical Plan.
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Claim Appeals. As of the Closing Time, Omnova shall have sole responsibility for the determination of claim appeals filed by Omnova Employees under the Omnova Medical Plan. Claim appeals filed by employees of Omnova under the GenCorp Medical Plan will be determined by GenCorp under the GenCorp Medical Plan.
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Claim Appeals. In the event that PORI makes only partial payment or denies payment of a Clean Claim, Hospital may appeal the decision by sending a letter marked "Appeal Request" to the Accounts Payable Department at PORI. Such letter shall contain the following information: Hospital name, date of service, date of billing, date of partial payment or payment denial, and the reason(s) the claim merits consideration. The appeal must be submitted to PORI within sixty (60) days of the date of partial payment or denial. Appeals submitted after the sixty (60) day limit shall be considered null and void. PORI will contact the Hospital with an appeal decision within forty five (45) days. If at that time, Hospital does not agree with PORI's appeal decision, the Hospital may appeal to DHS. The appeal must be submitted to DHS within sixty (60) days of PORI's appeal decision. The DHS decision is final. If DHS finds in favor of the Hospital, PORI will pay the Hospital within thirty (30) days of receipt of DHS's final decision. In the event of any dispute arising from any claim submitted by the Hospital, each party shall have access to all reasonable and necessary documents and records that would, at the discretion of each party, tend to sustain its claim (subject to applicable laws and regulations).
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Related to Claim Appeals

  • Administrative Appeals An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

  • Review and Appeal (a) Each Party shall establish or maintain judicial, quasi-judicial, or administrative tribunals or procedures for the purpose of the prompt review and, where warranted, correction of final administrative actions regarding matters covered by this Treaty. Such tribunals shall be impartial and independent of the office or authority entrusted with administrative enforcement and shall not have any substantial interest in the outcome of the matter.

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • Appeals a. Should the filer be dissatisfied with the Formal Dispute determination, a written appeal may be filed with the Chief Procurement Officer, by mail or email, using the following contact information: Chief Procurement Officer Procurement Services A Division of the Office of General Services 00xx Xxxxx, Xxxxxxx Xxxxx Xxxxxx Xxxxx Xxxxx Xxxxxx, XX 00000 Email: xxxxxxxx.xxxxxxxx@xxx.xx.xxx Subject line: Appeal – Attn: Chief Procurement Officer

  • Appeals Procedure If Employee appeals to the Administrator, Employee or his authorized representative may submit in writing whatever issues and comments he believes to be pertinent. The Administrator shall reexamine all facts related to the appeal and make a final determination of whether the denial of benefits is justified under the circumstances. The Administrator shall advise Employee in writing of:

  • Appeals Process A. The Contractor’s appeal process shall, at a minimum:

  • Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

  • COMPLAINTS AND APPEALS As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. WHEN YOU HAVE IDEAS We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. WHEN YOU HAVE QUESTIONS Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

  • Disciplinary Appeals All forms of disciplinary action which are not appealable to the Civil Service Commission or the courts, except written or oral reprimands and Forms 475, shall be subject to review through Steps 3, 4, 5 and 6 of the grievance procedure.

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