Appeals and Grievances. The MCP shall have written policies and procedures for an appeal and grievance system for members in compliance with the requirements of OAC rule 5160-26-08.4 and 42 CFR 438 Subpart F and shall include the participation of individuals authorized by the MCP to require corrective action. The MCP is prohibited from delegating the appeal or grievance process to another entity unless approved by ODM. These policies and procedures shall include a process by which members may file grievances and appeals with the MCP, and a process by which members may access the state’s fair hearing system through the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings (BSH).
Appeals and Grievances. MA-PD Sponsor agrees to comply with all requirements in Subpart M of 42 CFR Part 423 governing coverage determinations, grievances and appeals, and formulary exceptions. MA-PD Sponsor acknowledges that these requirements are separate and distinct from the appeals and grievances requirements applicable to the MA-PD Sponsor through the operation of its Part C or cost plan benefits.
Appeals and Grievances. Subcontractor shall, and shall require Provider to comply with United’s process for Covered Person appeals and grievances, including emergency appeals, as set forth in the provider manual. This shall include but not be limited to the following:
(a) Assisting a Covered Person by providing appeal forms and contact information, including the appropriate address, telephone number and/or fax number for submitting appeals for United and/or State level review; and
(b) Displaying notices in public areas of Subcontractor’s and/or Provider’s facility(ies) of a Covered Person’s right to appeal adverse actions affecting Covered Services in accordance with LDH’s rules and regulations, subsequent amendments, and any and all consent decrees and court orders. United shall ensure that Subcontractor and/or Provider have correct and adequate supply of such public notices.
Appeals and Grievances. (a) Internal. Contractor shall maintain an internal review process to resolve Enrollee’s written or oral expression of dissatisfaction regarding the Contractor and/or Provider, including appeals of claims and benefit determinations, and complaints relating to the scope of Covered Services required to be provided under the QHP. Contractor’s processes shall comply with applicable laws, rules and regulations, including, those set forth at Health and Safety Code Section 1368.
(b) Independent Medical Review. Contractor shall comply with applicable laws, rules and regulations relating to the external independent medical review process available to Enrollees for Covered Services that are disputed due to denial, modification, delay, or other limitation imposed by Contractor or a Participating Provider. The external medical review process shall be conducted in accordance with the requirements set forth at Insurance Code Section 10169 et seq. or Health and Safety Code Section 1374.30 et seq., as applicable.
Appeals and Grievances. Maintains information systems backups in a manner that mitigates disruption of service (including system Access) and ensures against loss of Data and Data integrity due to hardware or software failures, operational errors, destruction (physical and otherwise), and malicious attacks, including:
Appeals and Grievances. Subcontractor or Health Plan, as applicable, will provide general and targeted education to Provider regarding Provider’s obligations related to appeals and grievances by Covered Persons as set forth in section A.2.19 of the CRA, including, without limitation, when an emergency appeal is appropriate, and procedures for providing written certification thereof. Provider shall comply with the appeal process, including, but not limited to, the following:
(a) When a grievance or fair hearing request is filed by or on behalf of a Covered Person, Provider agrees to satisfy the following obligations in relation to the Covered Person’s grievance or fair hearing request:
(i) Provider must assist a Covered Person by providing appeal forms and contact information including the appropriate address, telephone number and/or fax number for submitting grievances or TennCare fair hearing requests.
(ii) Provider may, with Covered Person’s written consent, file a grievance or TennCare fair hearing request on Covered Person’s behalf. However, provider cannot file a request for Covered Person to receive continuation of benefits.
(iii) Provider agrees to timely comply with a request from Covered Person, Covered Person’s representative, TennCare or Subcontractor and/or Health Plan for information or records, including medical records, related to Covered Person’s grievance of fair hearing request.
(b) Provider must seek advance prior authorization when Provider feels he or she cannot order a drug on the TennCare PDL. Further, Provider shall take the initiative to seek prior authorization or change or cancel the prescription when contacted by a Covered Person or pharmacy regarding denial of a pharmacy service due to system edits (e.g., therapeutic duplication, etc.).
(c) Unless the State Contract requires otherwise, the appeals and grievances requirements above shall not apply to CoverKids Members. Review of CoverKids decisions shall be governed by TennCare Division rule 1200-13-21- .07 in accordance with T.C.A. §§ 4-5-202, 71-3-1106, 71-3-1110, and the Tennessee Title XXI Children’s Health Insurance Program State Plan.
Appeals and Grievances. A student who feels approval of an ESA was unfairly denied, may appeal the decision to the Associate Xxxx of Students. The Associate Xxxx of Student’s decision shall be a final determination.
Appeals and Grievances. I acknowledge my right to request reconsideration (an Appeal) in the case that client care is not certified by Managed Care Company. I understand that I would request an Appeal directly through my Managed Care Organization.
Appeals and Grievances. The MA D SNP Health Plan is required to provide AHCCCS with Appeals and Grievances reports as specified in Appendix 1 – Chart of Deliverables using the format detailed in the AHCCCS Grievance System Reporting Guide. The MA D SNP Health Plan is required to provide AHCCCS with a quarterly summary of Part C and D pre-service member appeals received and the outcome of those appeals. MA D SNP Health Plan is also required to provide AHCCCS with a summary of Independent Review Entity decisions received during the reporting period. In addition, MA D SNP Health Plan must provide service level detail on the appeals that were upheld and overturned (including a description of the action which is appealed). These reports will be used for informational purposes only. AHCCCS will not be using this information for oversight and monitoring.
Appeals and Grievances. (a) Internal. Contractor shall maintain an internal review process to resolve Enrollee’s written or oral expression of dissatisfaction regarding the Contractor and/or Provider, including appeals of claims and benefit determinations, and complaints relating to the scope of Covered Services required to be provided under the QDP. Contractor’s processes shall comply with applicable laws, rules and regulations, including, those set forth at Health and Safety Code Section 1368.
