Appeals Processing Requirements Sample Clauses

Appeals Processing Requirements. Members, or providers acting on the member’s behalf, shall have sixty (60) calendar days from the date of action notice within which to file an appeal. In accordance with 42 CFR 438.402, a provider, acting on behalf of the member and with the member’s written consent, may file an appeal. In accordance with 42 CFR 438.406, the Contractor shall ensure that oral requests seeking to appeal an action are treated as appeals. However, an oral request for an appeal must be followed by a written request, unless the member or the provider requests an expedited resolution. The Contractor shall acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall make a decision on standard, non-expedited, appeals within thirty (30) calendar days of receipt of the appeal. This timeframe may be extended up to fourteen (14) calendar days, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor shall give the member written notice of the reason for the delay. The Contractor shall maintain an expedited review process for appeals when the Contractor or the member’s provider determines that pursuing the standard appeals process could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function. The Contractor shall dispose of expedited appeals within forty-eight (48) hours after the Contractor receives notice of the appeal, unless this timeframe is extended pursuant to 42 CFR 438.408(c), which allows extensions under certain conditions. In addition to the required written decision notice, the Contractor shall make reasonable efforts to provide the member with prompt oral notice of the disposition of the appeal, including a phone call to the member. In accordance with 42 CFR 438.410, if the Contractor denies the request for an expedited resolution of a member’s appeal, the Contractor shall transfer the appeal to the standard thirty (30) calendar day timeframe and give the member written notice of the denial within two (2) days of the expedited appeal request. The Contractor shall also make a reasonable attempt to give the member prompt oral notice.
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Appeals Processing Requirements. Members, or providers acting on the member’s behalf, shall have sixty (60) calendar days from the date of action notice within which to file an appeal. In accordance with 42 CFR 438.402, a provider, acting on behalf of the member and with the member’s written consent, may file an appeal. In accordance with 42 CFR 438.406, the Contractor shall ensure that oral requests seeking to appeal an adverse benefit determination are treated as appeals. For oral appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal and its resolution. As of March 1, 2020, oral requests no longer need to be followed by a written request. The Contractor shall acknowledge receipt of each standard appeal within three
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Appeals Processing Requirements. Members shall have sixty (60) calendar days from the date of adverse benefit determination notice to file an appeal per 42 CFR 438.402(c)(2)(ii). In accordance with 42 CFR 438.402, a provider, acting on behalf of the member, and with the member’s written consent, may file an appeal. . In accordance with 42 CFR 438.402(c)(1)(ii)], and 42 CFR 438.402(c)(3)(ii), members, the provider, or authorized representative shall be allowed to file grievances orally or in writing. The Contractor shall ensure that oral requests seeking to appeal an adverse benefit determination are treated as appeals per 42 CFR 438.406(b)(3). For oral appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal and its resolution. The Contractor must acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall resolve each appeal and provide notice, as expeditiously as the member’s health condition requires, within State-established timeframes not to exceed thirty (30) calendar days from the day the Contractor receives the appeal per 42 CFR 438.408(a) and 42 CFR 438.408(b)(2). The Contractor must make a decision on standard, non-expedited, appeals within thirty (30) calendar days of receipt of the appeal. This timeframe may be extended up to fourteen (14) calendar days if the member requests the extension, or if the Contractor shows that there is need for additional information and that delay is in the member’s interest (upon State request), pursuant to 42 CFR 438.408(c)(1) and 42 CFR 438.408(b)(2). In accordance with 42 CFR 438.408(c)(2)(i)-(iii) and 42 CFR 438.408(b), if the timeframe is extended, for any extension not requested by the member, the Contractor must make reasonable efforts to give the member prompt oral notice of the delay and give the member written notice, within two (2) calendar days, and include the reason for the decision and inform the member of their right to file a grievance if he or she disagrees with that decision of the reason for the delay. In accordance with 42 CFR 438.410(a), the Contractor shall maintain an expedited review process for appeals when the Contractor or the member’s provider determines that pursuing the standard appeals process could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function. In accordance with 42 CFR 438.408(a) and 42 CFR 438.408(b)(3), the Contractor must resolve each expedited appeal and provide notice as ...
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Appeals Processing Requirements. Members, or providers acting on the member’s behalf, shall have sixty (60) calendar days from the date of action notice within which to file an appeal. In accordance with 42 CFR 438.402, a provider, acting on behalf of the member and with the member’s written consent, may file an appeal. In accordance with 42 CFR 438.406, the Contractor shall ensure that oral requests seeking to appeal an action are treated as appeals. However, an oral request for an appeal must be followed by a written request, unless the member or the provider requests an expedited resolution. The Contractor shall acknowledge receipt of each standard appeal within three
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Appeals Processing Requirements. Members, or providers acting on the member’s behalf, shall have sixty (60) calendar days from the date of action notice within which to file an appeal. In accordance with 42 CFR
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Appeals Processing Requirements. Members shall have sixty (60) calendar days from the date of adverse benefit determination notice to file an appeal per 42 CFR 438.402(c)(2)(ii). In accordance with 42 CFR 438.402, a provider, acting on behalf of the member, and with the member’s written consent, may file an appeal. . In accordance with 42 CFR 438.402(c)(1)(ii), and 42 CFR 438.402(c)(3)(ii), members, the provider, or authorized representative shall be allowed to file grievances orally or in writing. The Contractor shall ensure that oral requests seeking to appeal an adverse benefit determination are treated as appeals per 42 CFR 438.406(b)(3). For oral appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal and its resolution. The Contractor must acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall resolve each appeal and provide notice, as expeditiously as the member’s health condition requires, within State-established timeframes not to exceed thirty (30) calendar days from the day the Contractor receives the appeal per 42 CFR 438.408(a) and 42 CFR 438.408(b)(2). The Contractor must make a decision on standard, non-expedited, appeals within thirty
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Appeals Processing Requirements. Members shall have sixty (60) calendar days from the date of action notice to file an appeal. In accordance with 42 CFR 438.402, a provider, acting on behalf of the member, and with the member’s written consent, may file an appeal. In accordance with 42 CFR 438.406, the Contractor shall ensure that oral requests seeking to appeal an adverse benefit determination are treated as appeals. For oral appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal and its resolution. As of March 1, 2020, oral requests no longer need to be followed by a written request. The Contractor must acknowledge receipt of each standard appeal within three (3) business days. The Contractor must make a decision on standard, non-expedited, appeals within thirty (30) calendar days of receipt of the appeal. This timeframe may be extended up to ten (10) business days, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor must give the member written notice of the reason for the delay.
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Appeals Processing Requirements. Members, or providers acting on the member’s behalf, shall have thirty-three (33) calendar days from the date of action notice within which to file an appeal. In accordance with 42 CFR 438.402, a provider, acting on behalf of the member and with the member’s written consent, may file an appeal. In accordance with 42 CFR 438.406, the Contractor shall ensure that oral requests seeking to appeal an action are treated as appeals. However, an oral request for an appeal shall be followed by a written request, unless the member or the provider requests an expedited resolution. The Contractor shall acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall make a decision on standard, non-expedited, appeals within thirty (30) calendar days of receipt of the appeal. This timeframe may be extended up to fourteen (14) calendar days, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor shall give the member written notice of the reason for the delay. The Contractor shall maintain an expedited review process for appeals when the Contractor or the member’s provider determines that pursuing the standard appeals process could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function. The Contractor shall dispose of expedited appeals within forty-eight
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Related to Appeals Processing Requirements

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  • INVOICING REQUIREMENTS A. Upon acceptance of work by the Service Coordinator, the Contractor shall submit the invoice (and supporting documents where applicable) to the appropriate County department per the issued Delivery Order within thirty (30) calendar days of the acceptance. At minimum, all invoice shall contain the following information: • Correct Delivery Order number • Description of work performed to include the manufacturer name, original make and model number(s) of parts and equipment installed. • Start and ending date of the work • Location of the work • Total labor categorized per the Bid Response Form and rounded to the nearest (30) minutes • Itemized list of materials used according to the original manufacturer’s part name and part number. ▪ Unit price and quantity shall be provided on the invoice for each part • Applicable sales tax for materials purchased should be listed separately • Markdown/mark-ups for material shall be listed as a line item on the invoice. • Approved shipping charges shall be listed separately • Permit and special equipment rental cost for reimbursement (if applicable) • Invoice total B. Proof of purchase for all reimbursable expense must be submitted with the invoice showing the actual cost for all reimbursable expenses by the County, including but not limited to, parts, shipping, sales tax, permits, specialty equipment rentals, etc. The Contractor shall provide a separate service ticket for each work day as verification of actual labor spent on the project daily. C. The Contractor shall not combine charges for multiple Delivery Orders on the same invoice. Each Delivery Order must be invoiced separately. D. The County will review invoices for the required information. The County will have the authority to reject invoices based on improper invoice format and lack of supporting documents. E. The Contractor shall not invoice the County for any work not accepted by the County. Should the County received such invoices, they will be rejected. F. Unless otherwise authorized by the corresponding department in writing, delivery of invoices and back-up documentation via e-mail and/or fax is not allowed under this contract. All invoices shall be mailed or hand delivered to the appropriate Department as referenced as the “Invoice To:” location and on the Delivery Order. G. The Contractor shall submit monthly statements of unpaid invoices to each department ordering services under this contract. The Contractor shall not combine statements for different Departments utilizing this contract. • Statement date • Invoice numbers • Invoice dates • Invoice total or unpaid balance if different from invoice total • Delivery order number corresponding to each invoice listed • Balance carry forward • Cumulative outstanding balance Statements shall be sent to the corresponding Department’s, fiscal department, and the Contract Administrator by the 15th day of each month for service performed in the prior month and upon request by the County.

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