Enrollee Appeals and Grievances Sample Clauses

Enrollee Appeals and Grievances. Internal Grievances and Appeals. Contractor shall maintain an internal review process to resolve Enrollee’s written or oral expression of dissatisfaction regarding the Contractor and Participating Providers, including appeals of claim and benefit determinations, and complaints relating to the scope of Covered Services required to be covered under the QDP. Contractor’s processes shall comply with State and Federal laws, rules and regulations relating to enrollee rights and appeals processes, specifically including grievance requirements, set forth at Health and Safety Code § 1368 regardless of the State Regulator for the Contractor’s QDPs.
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Enrollee Appeals and Grievances 

Related to Enrollee Appeals and Grievances

  • 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.

  • COMPLAINTS AND GRIEVANCES 22.01 It is the mutual desire of the parties to this Agreement that reasonable and legitimate complaints and grievances of employees shall be dealt with as quickly as possible.

  • Grievances and Appeals a. If you have questions about any pediatric dental services received, please first discuss the matter with your Dental Provider. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center. You can also email questions by accessing the “Contact Us” section of the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.

  • Policy Grievances Where either party to this agreement disputes the general application, interpretation or alleged violation of an article of this agreement, the dispute shall be discussed initially with the General Manager, his/her designate or the Union within 30 calendar days of the occurrence. Where no satisfactory agreement is reached, either party, within a further 30 calendar days, may submit the dispute to arbitration, as set out in Article 9 of this agreement.

  • COMPLAINT AND GRIEVANCE PROCEDURE 1. When a member has any grievance or complaint, he shall forthwith convey to his immediate superior, orally 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.

  • Grievances and Complaints 5.1 It is the mutual desire of the parties hereto that grievances and complaints relative to this Agreement or working conditions generally shall be adjusted as quickly as possible.

  • Policy Grievance – Union Grievance The Union may institute a grievance alleging a general misinterpretation or violation of this Agreement by the Employer by submitting a written grievance at Step No. 1 within twenty (20) days after the circumstances have occurred. This section shall not apply to disciplinary grievances or application of competitive clauses under this Agreement.

  • Policy Grievance – Employer Grievance The Employer may institute a grievance alleging a general misinterpretation or violation by the Union or any employee by filing a written grievance with the Bargaining Unit President, with a copy to the Labour Relations Officer within twenty (20) days after the circumstances have occurred. A meeting will be held between the parties within ten (10) days. The Union shall reply within ten (10) days after the meeting, and failing settlement, the matter may be referred to arbitration.

  • Health and Safety Grievances A. It is the policy of the State employer to enforce safety and health, policies, procedures, and work practices and protect employees from harm in connection with State operations.

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