Common use of Appeal Procedure Clause in Contracts

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest.

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest.

Appeal Procedure. The definition of an appeal is an action taken by you with respect to your disagreement with our non-coverage of or non-payment for a serviceservice including denial, denialsreductions, reductions or termination terminations of services, denial of enrollment, or your involuntary disenrollment from the program. Information on the appeal process will be provided to you in writing when you enroll and at least annually thereafter. You will also be notified in writing if your LIFE Provider: • will Will not cover or pay for a service that you are requesting. • deniesDenies, reduces, or terminates a serviceservice you already receive. • is Is denying you enrollment into LIFE. • is initiating an involuntary disenrollment Is involuntarily disenrolling you from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. What you appeal determines where your appeal will be heard. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with If you believe that your care plan or conditions of participationlife, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to payhealth, or being out of ability to regain or maintain maximum function would be seriously jeopardized if you do not receive the service area for more than 30 calendar days without prior approved arrangementsin question, will automatically be considered you can request that your LIFE Provider speed up the appeal process. This is called an expedited appeal. If you appeal: • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of under the notice to you. following conditions: o If your Your LIFE Provider is proposing to terminate or reduce services that you are currently receiving, and you have requested the continuation; and o If you You agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you You will be notified in writing of the date when and time of that review to where your appeal will be heard. • You will have an opportunity to present evidence related to your disputedispute in person, as well as in writing. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe response describing the appeal, actions taken, and the outcome of the reviewappeal. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right awayas quickly as your health condition requires. • If the decision is not fully in your favor, a copy of the written report from the independent review entity response will be forwarded immediately to CMS and the Department. You will also be notified in writing of your any additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interesthave.

Appeal Procedure. If a claim is denied, the claimant may write to the Plan Administrator (or to the joint board in cases of claims for disability benefits) for a review of the claim on appeal. The definition of claimant must request the review on appeal within 60 days after the claim is denied. In cases involving disability, however, the period to file an appeal is action taken by you with respect extended to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar 180 days of after the date the claim is denied. A claimant who fails to submit an appeal request within the 60 or 180 day period (as applicable) will have no further right to appeal. As part of the appeal review procedure, the claimant will be allowed to: • submit additional documents, records, and information relating to the claim; • request access to and receive copies (free of charge) of all plan documents, records, and other information affecting the claim; • appeal the denial in writing; and • have someone act as the claimant’s representative in the appeal procedure. The Plan Administrator’s or joint board’s review of a claim on appeal will take into account all comments, documents, records, and other information relating to the claim submitted by the claimant, without regard to whether such information was submitted or considered in the initial claim determination. Within 60 days (or 120 days in some cases) after you file your request, the Plan Administrator will notify you of the final decision. If the Plan Administrator denies the claim on appeal (in whole or in part), it will provide the claimant with a notice was sent that advises the claimant of the type of information included in the initial notice of claim denial and the right to you. An involuntary disenrollment for non-compliance with your care plan or conditions receive (upon request and free of participationcharge) copies of all documents, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to payrecords, or being out other information that were submitted to the plan, considered by the plan, or generated in the course of making the service area benefit determination. For claims involving disability determinations, the appeal review period is reduced to 45 days (the review period can be extended for more than 30 calendar up to another 45 days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of with advance written notice) after the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if date the appeal is not resolved in your favorfiled. • An independent The review entity will review your of any appeal and you that involves disability determinations based on a medical judgment will be notified performed, without deference to the initial determination, by consulting with a qualified health care professional who: (a) has appropriate experience in writing the field of medicine involved; and (b) was neither consulted in connection with the initial denial nor a subordinate of any such individual. When ruling upon both the initial claims and Appeals, the Plan Administrator and the joint board shall have full discretionary authority to determine all questions arising in the administration, interpretation and application of the date Plan. A decision on review shall be final and time of that binding. If a claimant fails to file a request for review according to the Plan’s claim procedures, the claimant shall have an opportunity no rights to present evidence related review and no right to your dispute. • You will receive a written report bring action in any court, and the denial of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, claim shall be final and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interestbinding.

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Providerwe: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is ; are denying enrollment into LIFE. • is ; or are initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the our decision if you do not agree with the decisionit. You must request an appeal within 30 calendar days of the date the our notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider We will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the our notice to you. o If your LIFE Provider is ; if we are proposing to terminate or reduce services that you are currently receiving; and o If if you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity impartial party will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s third party review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider we will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent third party review entity will be forwarded immediately to CMS the federal government, the Pennsylvania Department of Human Services and the DepartmentLocal Area Agency on Aging. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider We will assist you with your appealin choosing which to pursue and forward the appeal to the appropriate entity. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider we speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest.