Common use of Appeals and Grievances Clause in Contracts

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. (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 including, those relating to the scope of Covered Services required to be provided under the QHPQHP and/or relating to Medical Necessity. Contractor’s processes shall comply with applicable laws, rules and regulations, including, those set forth at Health and Safety Code Section 13681370.2. (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 Health Care 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. (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 including, those relating to the scope of Covered Services required to be provided under the QHPQHP and/or relating to Medical Necessity. Contractor’s processes shall comply with applicable laws, rules and regulations, including, those set forth at Health and Safety Code Section 13681370.2. (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 Health Care 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. (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 QHPSADP. Contractor’s processes shall comply with applicable laws, rules and regulations, including, those set forth at Health and Safety Code Section 1368, if applicable. (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 Health Care 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.