Common use of Appeals Process and Standard and Expedited Reviews Clause in Contracts

Appeals Process and Standard and Expedited Reviews. Enrollees have the right to appeal most adverse “action” issued by the Contractor, the Contractor’s subcontractors or providers. a. Allow the enrollee, or enrollee’s authorized representative (requires written consent from the enrollee) acting on behalf of the enrollee to file an appeal, either orally or in writing, and unless he or she requests an expedited resolution, must follow an oral filing with a written, signed, appeal. Per 42 CFR 438.02(b) a provider, acting on behalf of the enrollee and with the enrollee’s written consent, may file a recipient appeal with the Contractor and through the State Fair Hearing Process, as described in this contract. b. Acknowledge receipt of each appeal. c. Ensure that the individuals who make decisions on appeals were not involved in any previous level of review or decision making. d. Ensure that the individuals who, if deciding on any of the following, are health care professionals with the appropriate clinical expertise in treating the enrollee’s condition or disease. i. An appeal of a denial that is based on lack of medical necessity. ii. An appeal that involves clinical issues. e. Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing unless the enrollee or the provider appealing on the enrollee’s behalf requests expedited resolution. f. Provide the enrollee a reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing. (The Contractor must inform the enrollee of the limited time available for this, especially in the case of expedited resolution.) g. Provide the enrollee and his or her representative opportunity, before and during the appeals process, to examine the enrollee’s case file, including any medical records and any other documents and records considered during the appeals process. h. Include as parties to the appeal the enrollee and his or her representative or the legal representative of a deceased enrollee’s estate. i. Continue benefits while the Contractor’s appeal or the State fair hearing is pending, in accordance with 42 CFR § 438.420, when all of the following criteria are met: i. The enrollee or the provider on behalf of the enrollee files the appeal within ten (10) calendar days of the Contractor’s mail date of the notice of adverse action or prior to the effective date of the Contractor’s notice of adverse action; and ii. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; and iii. The services were ordered by an authorized provider; and iv. The original period covered by the initial authorization has not expired; and v. The enrollee requests extension of benefits. If the final resolution of the appeal is adverse to the enrollee, that is, the Contractor’s adverse action is upheld, the Contractor may pursue recovery of the cost of services furnished to the enrollee while the appeal was pending, to the extent that the services were furnished solely because of the requirements listed above, and in accordance with the policy described in 42 CFR §§ 431.230(b) and 438.420.

Appeals Process and Standard and Expedited Reviews. Enrollees have the right to appeal most adverse “action” issued by the Contractor, the Contractor’s subcontractors or providers. a. i. Allow the enrollee, or enrollee’s authorized representative (requires representative(requires written consent from the enrollee) acting on behalf of the enrollee to file an appeal, either orally or in writing, and unless he or she requests an expedited resolution, must follow an oral filing with a written, signed, appeal. Per 42 CFR 438.02(b) a provider, acting on behalf of the enrollee and with the enrollee’s written consent, may file a recipient appeal with the Contractor and through the State Fair Hearing Process, as described in this contract. b. ii. Acknowledge receipt of each appeal. c. iii. Ensure that the individuals who make decisions on appeals were not involved in any previous level of review or decision making. d. iv. Ensure that the individuals who, if deciding on any of the following, are health care professionals with the appropriate clinical expertise in treating the enrollee’s condition or disease. i. a. An appeal of a denial that is based on lack of medical necessity. ii. b. An appeal that involves clinical issues. e. v. Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing unless the enrollee or the provider appealing on the enrollee’s behalf requests expedited resolution. f. vi. Provide the enrollee a reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing. (The Contractor must inform the enrollee of the limited time available for this, especially in the case of expedited resolution.) g. vii. Provide the enrollee and his or her representative opportunity, before and during the appeals process, to examine the enrollee’s case file, including any medical records and any other documents and records considered during the appeals process. h. viii. Include as parties to the appeal the enrollee and his or her representative or the legal representative of a deceased enrollee’s estate. i. ix. Continue benefits while the Contractor’s appeal or the State fair hearing is pending, in accordance with 42 CFR § 438.420, when all of the following criteria are met: i. a. The enrollee or the provider on behalf of the enrollee files the appeal within ten (10) calendar days of the Contractor’s mail date of the notice of adverse action or prior to the effective date of the Contractor’s notice of adverse action; and ii. b. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; and iii. c. The services were ordered by an authorized provider; and iv. d. The original period covered by the initial authorization has not expired; and v. e. The enrollee requests extension of benefits. If the final resolution of the appeal is adverse to the enrollee, that is, the Contractor’s adverse action is upheld, the Contractor may pursue recovery of the cost of services furnished to the enrollee while the appeal was pending, to the extent that the services were furnished solely because of the requirements listed above, and in accordance with the policy described in 42 CFR §§ 431.230(b) and 438.420.