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 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

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 ...

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

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

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

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.

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