If Left Unresolved, Member Complaints About the Actions or Decisions

question 85

Multiple Choice

If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info

• A) A Level One appeal, and the member has the right to a further appeal
• B) A Level Two appeal, and the reviewer's decision is final and binding
• C) An independent external appeal, and the member has the right to a further appeal
• D) Arbitration, and the reviewer's decision is final and binding

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Definitions:

Intangible Nature

The aspect of something that cannot be touched or physically measured, often related to abstract qualities like culture or knowledge.

Legal Work

Professional tasks and activities carried out in the context of practicing law, including research, litigation, and legal advice.

Political Corruption

The abuse of power by government officials for private gain, which can undermine democracy, economic development, and the rule of law.

White-collar

Relating to the class of jobs that typically involve mental or clerical work as opposed to manual labor.