Common use of Agreements with Providers and Subcontractors Clause in Contracts

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors at the time they enter into a Network Provider agreement or a Subcontract about: (1) the Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the Enrollee’s right to file Grievances and Appeals, and the requirements and timeframes for filing a Grievance or Appeal; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the Enrollee’s right to request a State Fair Hearing after the Contractor has made a determination on an Enrollee's Appeal which is adverse to the Enrollee; and (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's legal guardian, or other authorized representative has the right to request that the services be continued pending the outcome of the Appeal or State Fair Hearing if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services; (B) The Contractor’s written agreements with its Providers and Subcontractors shall contain provisions stating that: (1) if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor; (2) the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors shall, at the time they enter the Contractor enters into an agreement with a Network Provider agreement or a Subcontract aboutcontract with a Subcontractor, inform the Provider or Subcontractor of the following: (1) the Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the EnrolleeAggrieved Person’s right to file Grievances and Appeals, request Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the EnrolleeAggrieved Person’s right to request a State Fair Hearing after the Contractor has made a determination on an Enrollee's the Appeal which request that is adverse to the Enrollee; and (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's ’s legal guardian, guardian or other authorized representative has the right to request that the services be continued pending the outcome of the Appeal or State Fair Hearing if the Enrollee requests continuation of services within the required timeframetime frame; and (ii) that if the Appeal or State Fair Hearing decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor shall ensure its Providers and Subcontractors shall not bill Enrollees for Covered Services any amount greater than would be owed if the Provider or Subcontractor provided the Covered Services directly. (C) The Contractor’s written agreements with its Providers and Subcontractors shall contain provisions stating thatstating: (1) that if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor;; and (2) that the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; , or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor Contactor shall inform Providers and Subcontractors at the time they enter it enters into a Network contract with the Provider agreement or a Subcontract Subcontractor about: (1) the Enrollee Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the Enrollee’s right to file Grievances and Appeals, Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the Enrollee’s right to request a State Fair Hearing after the Contractor has made a determination on an the Enrollee's ’s Appeal which is adverse to the Enrollee; and; (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's legal guardian, or other authorized representative has the ’s right to request continuation of benefits that the services Contractor seeks to reduce or terminate during an Appeal or State Fair Hearing filing, if filed within the allowable timeframes, and that the Enrollee may be liable for the cost of any continued pending the outcome of benefits while the Appeal or State Fair Hearing is pending if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing final decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor’s Contractor shall ensure that its Subcontractors and Providers shall not bill Enrollees for Covered Services any amount greater than would be owed if the Subcontractor or Provider provided the Covered Services directly. (C) The Contractors written agreements with its Subcontractors and Providers and Subcontractors shall contain provisions stating thata provision stating: (1) that if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor;; and (2) that the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; , or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor Contactor shall inform Providers and Subcontractors at the time they enter it enters into a Network contract with the Provider agreement or a Subcontract Subcontractor about: (1) the Enrollee Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the Enrollee’s right to file Grievances and Appeals, Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the The availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the Enrollee’s right to request a State Fair Hearing after the Contractor has made a determination on an the Enrollee's ’s Appeal which is adverse to the Enrollee; and; (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's legal guardian, or other authorized representative has the ’s right to request continuation of benefits that the services Contractor seeks to reduce or terminate during an Appeal or State Fair Hearing filing, if filed within the allowable timeframes, and that the Enrollee may be liable for the cost of any continued pending the outcome of benefits while the Appeal or State Fair Hearing is pending if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing final decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor’s Contractor shall ensure that its Subcontractors and Providers shall not bill Enrollees for Covered Services any amount greater than would be owed if the Subcontractor or Provider provided the Covered Services directly. (C) The Contractors written agreements with its Subcontractors and Providers and Subcontractors shall contain provisions a provision stating that: (1) that if the Subcontractor or Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider Subcontractor or Subcontractor; (2) the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directlyProvider.

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors at the time they enter into a Network Provider agreement or a Subcontract contract about: (1) the Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the EnrolleeAggrieved Person’s right to file Grievances and Appeals, Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the EnrolleeAggrieved Person’s right to request a State Fair Hearing after the Contractor has made a determination on an the Enrollee's ’s Appeal which is adverse to the Enrollee; and (5) if the Contractor makes an Adverse Benefit Determination Determinations to reduce, suspend suspend, or terminate services: (i) that the Enrollee, the Enrollee's ’s legal guardian, guardian or other authorized representative has the right to request that the services be continued pending the outcome of the Appeal or State Fair Hearing if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor’s Contractor shall ensure that its Subcontractors and Providers shall not bill Enrollees for Covered Services any amount greater than would be owed if the Subcontractor or Provider provided the Covered Services directly. (C) The Contractors written agreements with its Subcontractors and Providers and Subcontractors shall contain provisions stating thatstating: (1) that if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor;; and (2) that the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; , or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors at the time they enter it enters into a Network contract with the Provider agreement or a Subcontract Subcontractor about: (1) the Enrollee Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424;and (2) the EnrolleeAggrieved Person’s right to file Grievances and Appeals, Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the EnrolleeAggrieved Person’s right to request a State Fair Hearing after the Contractor has made a determination on an the Enrollee's ’s Appeal which is adverse to the Enrollee; and; (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's legal guardian, or other authorized representative has the Aggrieved Person’s right to request continuation of benefits that the services Contractor seeks to reduce or terminate during an Appeal or State Fair Hearing filing, if filed within the allowable time frames, and that the Enrollee may be liable for the cost of any continued pending the outcome of benefits while the Appeal or State Fair Hearing is pending if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing final decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor shall ensure that its Subcontractors and Providers shall not bill Enrollees for Covered Services any amount greater than would be owed if the Subcontractor or Provider provided the Covered Services directly. (C) The Contractor’s written agreements with its Subcontractors and Providers and Subcontractors shall contain provisions stating that:a provision stating (1) that if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor;; and (2) that the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; , or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors at the time they enter into a Network Provider agreement or a Subcontract contract about: (1) the Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the EnrolleeAggrieved Person’s right to file Grievances and Appeals, Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the EnrolleeAggrieved Person’s right to request a State Fair Hearing after the Contractor has made a determination on an the Enrollee's ’s Appeal which is adverse to the Enrollee; and (5) if the Contractor makes an Adverse Benefit Determination Determinations to reduce, suspend suspend, or terminate services: (i) that the Enrollee, the Enrollee's ’s legal guardian, guardian or other authorized representative has the right to request that the services be continued pending the outcome of the Appeal or State Fair Hearing if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor’s Contractor shall ensure that its Subcontractors and Providers shall not bill Enrollees for Covered Services any amount greater than would be owed if the Subcontractor or Provider provided the Covered Services directly. (C) The Contractors written agreements with its Subcontractors and Providers and Subcontractors shall contain provisions stating thata provision stating: (1) that if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor;; and (2) that the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; , or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors at the time they enter into a Network Provider agreement or a Subcontract about: (1) the Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § 438.400 through 42 CFR § 438.424; (2) the Enrollee’s right to file Grievances and Appeals, request Appeals and the requirements and timeframes for filing a Grievance or Appealfiling; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the Enrollee’s right to request a State Fair Hearing after the Contractor has made a determination on an Enrollee's the Appeal which if it is adverse to the Enrollee; and (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's legal guardian, or other authorized representative has the right to request that the services be continued pending the outcome of the Appeal or State Fair Hearing if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services;. (B) The Contractor shall ensure its Providers and Subcontractors shall not bill Enrollees for Covered Services any amount greater than would be owed if the Provider or Subcontractor provided the Covered Services directly. (C) The Contractor’s written agreements with its Providers and Subcontractors shall contain provisions stating thatstating: (1) that if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor;; and (2) that the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.

Agreements with Providers and Subcontractors. (A) The Contractor shall inform Providers and Subcontractors at the time they enter into a Network Provider agreement or a Subcontract about: (1) the Grievance, Appeal, and State Fair Hearing procedures and timeframes as specified in 42 CFR § i 438.400 through 42 CFR § i 438.424; (2) the Enrollee’s 's right to file Grievances and Appeals, and the requirements and timeframes for filing a Grievance or Appeal; (3) the availability of assistance to the Enrollee with filing Grievances and requesting Appeals; (4) the Enrollee’s 's right to request a State Fair Hearing after the Contractor has made a determination on an Enrollee's Appeal which is adverse to the Enrollee; and (5) if the Contractor makes an Adverse Benefit Determination to reduce, suspend or terminate services: (i) that the Enrollee, the Enrollee's legal guardian, or other authorized representative has the right to request that the services be continued pending the outcome of the Appeal or State Fair Hearing if the Enrollee requests continuation of services within the required timeframe; and (ii) that if the Appeal or State Fair Hearing decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of services; (B) The Contractor’s 's written agreements with its Providers and Subcontractors shall contain provisions stating that: (1) if the Provider or Subcontractor becomes insolvent or bankrupt, Enrollees shall not be liable for the debt of the Provider or Subcontractor; (2) the Enrollee shall not be held liable for Covered Services provided to the Enrollee for which: (i) the Department does not pay the Contractor; or (ii) the Department or the Contractor does not pay the individual or Provider that furnished the services under a contractual, referral or other arrangement; and (3) the Provider or Subcontractor shall not hold Enrollees liable for payments for Covered Services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor covered the services directly.