Internal Appeal Procedure Sample Clauses

Internal Appeal Procedure. If You are not satisfied with Our decision regarding Your Grievance, You have the right to submit an Appeal to Us within 180 days of Our decision regarding Your Grievance. You may file an appeal in writing or You may call MDwise Customer Service directly and a Customer Service Representative will assist You in filing the Appeal. We will acknowledge Your Appeal, orally or in writing, within three business days of Our receipt of it. We will continue to provide You with Coverage under this Contract pending the outcome of the Appeal. You may request continuation of Health Services during the Appeal process if an authorized Health Service is being terminate, reduced or suspended before the expiration of the original authorization date. Pre-service authorization requests and re-authorization request after a number of approved number of days, services, or visits expired do not apply. In the event of request for Concurrent Care Claim reviews beyond original authorization, You and Your provider will be notified of the Appeals process, as indicated in Section 8.4. We will document the substance of the Appeal and the actions taken. Your representative may act on Your behalf with respect to requesting an Appeal and the procedures involved. We allow You the opportunity for representation by anyone You choose, including a provider or attorney. For Urgent Grievance Appeals, a health care practitioner with knowledge of Your condition may act as Your representative. We will investigate the substance of the Appeal, including any aspects of clinical care involved. Our Appeal Committee (the Committee) will resolve the Appeal. The Committee shall be comprised of qualified individuals who were not involved in the investigation or resolution of the Grievance or involved in the matters giving rise to it. If the Appeal concerns health care procedures, treatments, or services that have been proposed, refused, or delivered, the Committee shall include one or more individuals who meet all of the following requirements
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Related to Internal Appeal Procedure

  • 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.

  • 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.

  • Complaints Procedure 18.1 If the Client has any cause for complaint in relation to the services provided by the Company, he should file a complaint as per the Company’s Complaint Handling policy which is available on the Company’s website.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • CLAIM PROCEDURES Claim forms or claim information as to the subject policy can be obtained by contacting Benmark, Inc. (800-544-6079). When the Named Fiduciary has a claim which may be covered under the provisions described in the insurance policy, they should contact the office named above, and they will either complete a claim form and forward it to an authorized representative of the Insurer or advise the named Fiduciary what further requirements are necessary. The Insurer will evaluate and make a decision as to payment. If the claim is payable, a benefit check will be issued in accordance with the terms of this Agreement. In the event that a claim is not eligible under the policy, the Insurer will notify the Named Fiduciary of the denial pursuant to the requirements under the terms of the policy. If the Named Fiduciary is dissatisfied with the denial of the claim and wishes to contest such claim denial, they should contact the office named above and they will assist in making an inquiry to the Insurer. All objections to the Insurer's actions should be in writing and submitted to the office named above for transmittal to the Insurer.

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