Common use of Appeals and Grievances Clause in Contracts

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. Subcontractor or Health Plan, as applicable, United 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: (ai) 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) a. 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) b. 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) c. Provider agrees to timely comply with a request from Covered Person, Covered Person’s representative, TennCare or Subcontractor and/or Health Plan United for information or records, including medical records, related to Covered Person’s grievance of fair hearing request. (bii) 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.). (ciii) 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. Subcontractor or Health Plan, as applicable, United 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: (ai) 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) a. 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) b. 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) c. Provider agrees to timely comply with a request from Covered Person, Covered Person’s representative, TennCare or Subcontractor and/or Health Plan United for information or records, including medical records, related to Covered Person’s grievance of fair hearing request. (bii) 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.). (ciii) 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 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. 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 publicly display notices regarding the appeal rights of Covered Persons. 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. Subcontractor or Health Plan, as applicable, United 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: (ai) 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) a. 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) b. 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) c. Provider agrees to timely comply with a request from Covered Person, Covered Person’s representative, TennCare or Subcontractor and/or Health Plan United for information or records, including medical records, related to Covered Person’s grievance of fair hearing request. (bii) 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.). (ciii) 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 21-.07 in accordance with T.C.A. §§ 4-5-5- 202, 71-3-1106, 71-3-1110, and the Tennessee Title XXI Children’s Health Insurance Program State Plan.