External Review of Grievances Sample Clauses

External Review of Grievances. You may pursue an External Appeal if You are not satisfied with Our Appeal decision. An Independent Review Organization ("IRO") is available for Appeals that involve an Adverse Determination of the following:
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External Review of Grievances. A Member may file a written request for an external review due to an adverse utilization review determination, an adverse determination of medical necessity, or a determination made by WHP or an agent of WHP that a proposed service by the treating Physician is Experimental/ Investigational. The request for an external review must be filed within forty-five (45) days after the Member is notified of the result of the Grievance. WHP will appoint an IRO certified by the Indiana Department of Insurance. WHP will be responsible for all costs associated with the review except for a $25 filing fee to be paid by the Member. WHP will cooperate with the IRO by promptly providing any information requested by the IRO. A Member who requests an external review is not subject to retaliation for exercising their right to appeal. A Member may use the assistance of other individuals including physicians, attorneys, friends, and family members throughout the review process and may submit additional information relating to the proposed service throughout the review process. A Member is expected to cooperate with the IRO by providing any requested medical information or authorizing the release of necessary medical information. Based on information gathered from the Member or the Member’s designee, WHP, the treating Physician and any additional information that the organization considers necessary and appropriate, the IRO will make a decision within ten (10) business days from the date the request is filed. If the Grievance is related to an illness, a disease, a condition, an injury or disability that would seriously jeopardize the Member’s life, health or ability to reach and maintain maximum function, the IRO will make a decision within seventy-two (72) hours of the time the expedited Appeal is filed. The IRO’s decision is binding upon WHP.
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Related to External Review of Grievances

  • External Review In the event of a final internal Adverse Benefit Determination, a Claimant may be entitled to an external review of the Claim. This request must be submitted in writing on an External Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external reviewer will render a recommendation within 45 calendar days unless the request meets expedited criteria, in which case it will be resolved in no later than 72 hours. The external reviewer’s recommendation will be binding. The external reviewer will notify the Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such recommendation. For detailed information about the external review process, please contact XxXxx’s Member Engagement Center.

  • Scope of Grievances A. A grievance may be filed if a management interpretation or application of the provisions of this Memorandum of Understanding adversely affects an employee's wages, hours or conditions of employment.

  • Investigation of Grievances The investigation of grievances shall not interfere with the orderly process of education in District 281.

  • Resolution of Grievances In the event of a grievance related to a matter of discipline or any dispute as to the interpretation, application or observance of the provisions of this Agreement other than discipline, it shall be handled in the following manner:

  • Recognition of Union Stewards and Grievance Committee In order to provide an orderly and speedy procedure for the settling of grievances, the Employer acknowledges the rights and duties of the Union Stewards. The Xxxxxxx shall assist any Employee, which the Xxxxxxx represents, in preparing and presenting her grievance in accordance with the grievance procedure.

  • Grievance A grievance is an alleged violation, misinterpretation, or misapplication of the terms of the negotiated agreement between the Board and the Association.

  • Disciplinary Grievances If the grievance is not resolved at Step 2, the Union may file a request for mediation with the Public Employment Relations Commission (PERC) in accordance with WAC 000-00-000, with a copy to the Office of Financial Management/SHR/Labor Relations Section (OFM/SHR/LRS) and the Human Resources Office within fifteen (15) days of receipt of the Step 2 decision. In addition to all other filing requirements, the request must include a copy of the grievance and all previous responses.

  • 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.

  • 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.

  • Arbitration of Grievances If a grievance brought under Division B (GRIEVANCES) of this Article is not resolved at Step Three of that procedure, the Association may submit the matter to arbitration. Notice of intent to arbitrate (Appendix D) must be filed with the President of the University within twenty (20) working days of the date of the decision at Step Three. If no notice of intent to arbitrate is filed within the time limit, the right to arbitrate is thereby waived.

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