Medicare Appeals Council Sample Clauses

Medicare Appeals Council.  If the ALJ decides against you, you must request a review by the Medicare Appeals Council within 60 days of receiving the ALJ’s decision.  For beneficiary-initiated appeals, the Appeals Council should make a decision within 90 days of receiving the request for a hearing. Federal District Court  If the Appeals Council decides against you, follow the directions in the denial to file for judicial review in federal district court.  You must file within 60 days of receiving the Appeals Council’s decision.  You must meet the amount in controversy requirement. The amount in controversy is adjusted annually.
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Medicare Appeals Council. If a Participant disagrees with the Integrated Administrative Hearing Officer’s decision, the Participant may appeal that decision further to the Medicare Appeals Council, which may overturn the Integrated Administrative Hearing Officer’s decision. An adverse Administrative Hearing decision may be appealed to the Medicare Appeals Council within 60 calendar days. This serves as the third level of appeal. These appeals must be filed with the FIDA-IDD Administrative Hearing Unit, which will forward the request for appeal and administrative record to the Medicare Appeals Council in the manner specified in the Three-way Contract. The Medicare Appeals Council will complete a paper review and will issue a decision within 90 calendar days. Benefits will continue pending an appeal in accordance with section IX.a.ii.12. CMS and NYSDOH/OPWDD will provide the Administrative Appeals Judges with FIDA-IDD Demonstration specific information.
Sample 1
Medicare Appeals Council. 3.7.1. The member may appeal adverse IAHO decisions to the Medicare Appeals Council. Xxxxx appealed to the MAC will be reviewed on the basis of the record compiled by the IAHO, and, upon request by the MAC, any supplemental record or argument submitted by the parties to the appeal. The Medicare Appeals Council will apply all Medicare and Medicaid coverage rules as specified in the MAP plan’s Member Handbook and the model contract between the participating plan and DOH, as well as the Evidence of Coverage of the exclusively aligned MAP-participating D-SNP.
Sample 1
Medicare Appeals Council. 3.7.1. If a member disagrees with the OAH decision, the member may appeal that decision further to the Medicare Appeals Council (MAC), which may overturn the decision. This serves as the third level of appeal. Xxxxx appealed to the MAC will be reviewed on the basis of the record compiled by OAH, and, upon request by the MAC, any supplemental record or argument submitted by the parties to the appeal. The Medicare Appeals Council will apply all Medicare and Medicaid coverage rules as specified in the MAP plan’s Member Handbook and the model contract between the participating plan and DOH, as well as the Evidence of Coverage of the exclusively aligned MAP-participating D-SNP.
Sample 1
Medicare Appeals Council. If a Participant disagrees with the Integrated Administrative Hearing Officer’s decision, the Participant may appeal that decision further to the Medicare Appeals Council, which may overturn the Integrated Administrative Hearing Office’s decision. The Medicare Appeals Council will apply all Medicare and Medicaid coverage rules as specified in Appendix A of this contract. The Participant submits his/her request for Medicare Appeals Council review to the Integrated Administrative Hearing Office. This must be done within sixty (60) calendar days of the date of the adverse decision by the Integrated Administrative Hearing Office. The Integrated Administrative Hearing Office will forward the Appeal and the record to the Medicare Appeals Council. These Appeals must be filed with the FIDA Administrative Hearing Unit, which will forward the request for Appeal and administrative record to the Medicare Appeals Council. The Medicare Appeals Council will complete a paper review and will issue a decision within ninety (90) calendar days from the receipt of the appeal request. Benefits will continue pending an Appeal in accordance with Section 2.13.1.2.2.12.
Sample 1

Related to Medicare Appeals Council

  • Health Care Committee A Health Insurance Committee shall be established and maintained with at least three (3) representatives appointed by the Association and three (3) representatives appointed by the Superintendent. The purpose of the Committee shall be to make recommendations designed to optimize the quality of health care available to District employees and improve cost effectiveness of the health insurance program. Committee members shall review data, work with the District insurance consultant, collaborate on making recommendations for changes in plan design, review bids by insurance companies, and ultimately consider recommending plan changes to their respective constituencies. The Committee is not empowered to unilaterally make changes in health care benefits without ratification by the Association and approval by the Board. The creation of the Committee does not diminish or in any way reduce the Board’s and Association’s rights or responsibilities.

  • SCHOOL ACT APPEALS 1. Where a pupil and/or parent/guardian files an appeal pursuant to Section 11 of the School Act and Board By-law of a decision of an employee, or in connection with or affecting such an employee:

  • How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.

  • Appeals Committee ‌ An Appeals Committee is hereby established composed of one member appointed by the Union, one member appointed by the Employer or by the Association, as the case may be, and a Public Member appointed by both these members.

  • HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.

  • Extended Health Care Plan (a) The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable Extended Health Care Plan.

  • Grievance Commissioner System This is to confirm the discussion of the parties during collective bargaining that they are committed to encouraging early discussion and resolution of labour relations issues at the local level and seek to resolve grievances in a timely and cost efficient manner. To that end, this is to confirm that pursuant to Article 8, the parties agree that the Employer and Union at individual nursing homes may agree to utilize the following process in order to resolve a particular grievance through the utilization of a joint mediation-arbitration procedure:

  • Medical Care Leave An Employee who is unable to make the necessary arrangements for maintenance of personal health care outside of scheduled work time, shall be granted time off with pay. Such time off shall not exceed sixteen (16) working hours per calendar year. Hours in excess of sixteen (16) hours per calendar year shall be deducted from the Employee's sick leave accumulation.

  • Grievance Commissioner The Employer and Union may mutually agree in writing to invoke the Commissioner Process rather than proceed to arbitration as set out in this Collective Agreement. All cases referred to arbitration where an employee has a grievance concerning discipline will only be referred to a Grievance Commissioner if the Employer and the Union agree in writing on all the facts. The parties may also agree to group grievances before a single Grievance Commissioner. A Grievance Commissioner (where more than one, acting in rotation) will set aside such time as may be requested by the Employer and the Union to consider and determine grievances referred to them. A Grievance Commissioner shall have the same powers and be subject to the same limitations as a Board of Arbitration hereunder, save and except as expressly provided in 9.18 to 9.22 hereof.

  • 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.

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