Common use of Additional Addressee Clause in Contracts

Additional Addressee. ‌ The PH-MCO must have administrative mechanisms for sending copies of information, notices and other written materials to a designated third party upon the request and signed consent of the Member. The PH-MCO must develop plans to process such individual requests and for obtaining the necessary releases signed by the Member to ensure that the Member's rights regarding confidentiality are maintained. I. Member Complaint, Grievance and DPW Fair Hearing Process‌ 1. Member Complaint, Grievance and DPW Fair Hearing Process‌ The PH-MCO must develop, implement, and maintain a Complaint and Grievance process that provides for settlement of Members' Complaints and Grievances and the processing of requests for DPW Fair Hearings as outlined in Exhibit GG of this Agreement, Complaint, Grievance, and DPW Fair Hearing Processes. The PH- MCO must use the templates provided by the Department in Exhibits GG(1) through GG(14) to inform Members regarding decisions and the process. The PH-MCO must have written policies and procedures approved by the Department, for resolving Member Complaints and for processing Grievances and DPW Fair Hearing requests, that meet the requirements established by the Department and the provisions of 40 P.S. 991.2101 et seq. (known as Act 68), Pennsylvania Department of Health regulations (28 Pa. Code Chapter 9), Pennsylvania Insurance Department regulations (31 Pa. Code CHs. 154 and 301) and 42 CFR 431.200 et seq. of the Federal Regulations. The PH-MCO must also comply with 55 Pa. Code 275 et seq. regarding DPW Fair Hearing Requests and 42 CFR 438.406(b). The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by the Department for operation in a HealthChoices Zone. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO must require each of its subcontractors to comply with the Member Complaint, Grievance, and DPW Fair Hearing Process. This includes reporting requirements established by the PH-MCO, which have received advance written approval by the Department. The PH-MCO must provide to the Department for approval, its written procedures governing the resolution of Complaints and Grievances and the processing of DPW Fair Hearing requests. There must be no delegation of the Complaint, Grievance and Fair Hearing process to a subcontractor without prior written approval of the Department. The PH-MCO must abide by the final decision of the Departments of Health or Insurance (as applicable) when a Member has filed an external appeal of a second level Complaint decision. When a Member files an external appeal of a second level Grievance decision, the PH-MCO must abide by the decision of the Department of Health’s certified review entity (CRE), which was assigned to conduct the independent external review, unless appealed to the court of competent jurisdiction. The PH-MCO must abide by the final decision of the Department of Public Welfare’s Bureau of Hearings and Appeals for those cases when an Recipient has requested a DPW Fair Hearing, unless requesting reconsideration by the Secretary of the Department of Public Welfare. Only the Member may appeal to Commonwealth Court. The decisions of the Secretary and the Court are binding on the PH-MCO.

Additional Addressee. ‌ The PH-MCO must have administrative mechanisms for sending copies of information, notices and other written materials to a designated third party upon the request and signed consent of the Member. The PH-MCO must develop plans to process such individual requests and for obtaining the necessary releases signed by the Member to ensure that the Member's rights regarding confidentiality are maintained. I. Member Complaint, Grievance and DPW DHS Fair Hearing Process‌ 1. Member Complaint, Grievance and DPW DHS Fair Hearing Process‌ The PH-MCO must develop, implement, and maintain a Complaint and Grievance process that provides for settlement of Members' Complaints and Grievances and the processing of requests for DPW DHS Fair Hearings as outlined in Exhibit GG of this AgreementGG, Complaint, Grievance, and DPW DHS Fair Hearing Processes. The PH- PH-MCO must use the required templates provided by the Department in Exhibits GG(1) through GG(14) to inform Members regarding decisions and the process. Templates GG(1) through GG(20) are available in Docushare. The PH-MCO must have written policies and procedures approved by the Department, for resolving Member Complaints and for processing Grievances and DPW DHS Fair Hearing requests, that meet the requirements established by the Department and the provisions of 40 P.S. §991.2101 et seq. (known as Act 68), Pennsylvania Department of Health DOH regulations (28 Pa. Code Chapter 9), Pennsylvania Insurance Department PID regulations (31 Pa. Code CHs. 154 and 301) and 42 CFR C.F.R. §431.200 et seq. of the Federal Regulations. The PH-MCO must also comply with 55 Pa. Code Chapter 275 et seq. regarding DPW DHS Fair Hearing Requests and 42 CFR C.F.R. §438.406(b). The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by the Department for operation in a HealthChoices ZoneDepartment. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereofversion. The PH-MCO must require each of its subcontractors Subcontractors to comply with the Member Complaint, Grievance, and DPW DHS Fair Hearing Process. This includes reporting requirements established by the PH-MCO, which have received advance written approval by the Department. The PH-MCO must provide to the Department for approval, its written procedures governing the resolution of Complaints and Grievances and the processing of DPW DHS Fair Hearing requests. There must be no delegation of the Complaint, Grievance and Fair Hearing process to a subcontractor Subcontractor without prior written approval of the Department. PH-MCO must adhere to the mechanisms and time-frames for reporting member complaints and grievances to the Department in the manner The Department has determined. The PH-MCO must abide by the final decision of the Departments of Health or Insurance (as applicable) DOH when a Member has filed an external appeal of a second level Complaint decision. When a Member files an external appeal of a second level Grievance decision, the PH-MCO must abide by the decision of the Department of HealthDOH’s certified review entity (CRE), which was assigned to conduct the independent external review, unless appealed to the court of competent jurisdiction. The PH-MCO must abide by the final decision of the Department of Public Welfare’s Bureau of Hearings and Appeals BHA for those cases when an Recipient a Member has requested a DPW DHS Fair Hearing, unless requesting reconsideration by the Secretary of the Department of Public WelfareDepartment. Only the Member may appeal to Commonwealth Court. The decisions of the Secretary and the Court are binding on the PH-MCO.

Additional Addressee. ‌ The PH-MCO Contractor must have administrative mechanisms for sending copies of information, notices and other written materials to a designated third party upon the request and signed consent of the Member. The PH-MCO Contractor must develop plans to process such individual requests and for obtaining the necessary releases signed by the Member to ensure that the Member's rights regarding confidentiality are maintained. I. Member Complaint, . Grievance and DPW Fair Hearing Process‌Process 1. Member Complaint, Grievance and DPW Fair Hearing Process‌ Process The PH-MCO Contractor must develop, implement, and maintain a Complaint and Grievance process that provides for settlement of Members' Complaints and Grievances and the processing of requests for DPW Fair Hearings as outlined in Exhibit GG of this Agreement. Complaints, Complaint, GrievanceGrievances, and DPW Fair Hearing ProcessesProcess. The PH- MCO must use the templates provided by the Department in Exhibits GG(1) through GG(14) to inform Members regarding decisions and the process. The PH-MCO Contractor must have written policies and procedures approved by the Department, for resolving Member Complaints and for processing Grievances and DPW Fair Hearing requests, that meet the requirements established by the Department and the provisions of Article XXI of the Insurance Company Law of 1921, as amended by the Act of June 17, 1998, (P.L. 464, No. 68), 40 P.S. 991.2101 et seq. (991.2101-991.2361) known as Act 68), Pennsylvania Department of Health 68 and corresponding Act 68 regulations (28 Pa. Code Chapter 9), Pennsylvania Insurance Department regulations (31 Pa. Code CHs. 154 and 301) and 42 CFR C.F.R. 431.200 et seq. seq of the Federal Regulations. The PH-MCO Contractor must also comply with 55 Pa. Code 275 et seq. regarding DPW Fair Hearing Requests and 42 CFR 438.406(b)Requests. The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by the Department for operation in a HealthChoices Zone. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO Contractor must require each of its subcontractors to comply with the Member Complaint, Grievance, and DPW Fair Hearing Process. This includes reporting requirements established by the PH-MCOContractor, which have received advance written approval by the Department. The PH-MCO Contractor must provide to the Department for approval, its written procedures governing the resolution of Complaints and Grievances and the processing of DPW Fair Hearing requests. There The standard notice required and outlined in Exhibit N of this Agreement, Denial Notices, must be no delegation of used in the Contractor's Complaint, Grievance and DPW Fair Hearing process and must be in accessible formats for individuals with vision impairments. In addition, the notice must be available for persons who do not speak English. For children in substitute care, notices must be sent to the County Children and Youth Agency with legal custody of a subcontractor without prior written approval child or to the court authorized juvenile probation office with primary supervision of a juvenile, provided the Department. The PH-MCO knows that the child is in substitute care and the address of the custodian of the child. The Contractor must abide by the final decision of the Departments of Health or Insurance (as applicable) when a Member has filed an external appeal of a second level Complaint complaint decision. When a Member files an external appeal of a second level Grievance grievance decision, the PH-MCO Contractor must abide by the decision of the Department of Health’s Health certified utilization review entity (CREURE), which was assigned to conduct the independent external review, unless appealed to the court of competent jurisdiction. The PH-MCO Contractor must abide by the final decision of the Department of Public Welfare’s 's Bureau of Hearings and Appeals for those cases when an Recipient MA Consumer has requested a DPW Fair Hearing, unless requesting reconsideration by the Secretary of the Department of Public Welfare. Only Welfare or appealing to the Member may appeal to Commonwealth Court. The decisions court of the Secretary and the Court are binding on the PH-MCOcompetent jurisdiction.