Common use of Appeals Processing Requirements Clause in Contracts

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.

Appeals Processing Requirements. Members, or providers acting on the member’s behalf, Members 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 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 must acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall 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 ten (1410) calendar business days, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor shall must 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 must 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(c438.408 (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 must 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 must also make a reasonable attempt to give the member prompt oral notice, including a phone call to the member. In accordance with 42 CFR 438.408, written notice of appeal disposition must be provided to the member. Notice shall be provided within five (5) business days of resolution. For notice of an expedited resolution, the Contractor must also make reasonable efforts, including a phone call to the member, to provide oral notice. The written notice of the resolution must include the results of the resolution and the date it was completed. For appeals not resolved wholly in favor of the member, the written notice must include the right to request a State fair hearing, including the procedures to do so and the right to request to receive benefits while the hearing is pending, including instructions on how to make the request. This shall also include notice that the member may be held liable for the cost of those benefits if the State hearing upholds the Contractor’s action as set forth in Section 4.12.7.

Appeals Processing Requirements. Members, or providers acting on the member’s behalf, Members 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 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 adverse benefit determination are treated as appeals. HoweverFor oral appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal and its resolution. As of March 1, an 2020, oral request for an appeal must requests no longer need to be followed by a written request, unless the member or the provider requests an expedited resolution. The Contractor shall must acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall 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 ten (1410) calendar business days, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor shall must 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 must 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(c438.408 (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 must 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 must also make a reasonable attempt to give the member prompt oral notice, including a phone call to the member. In accordance with 42 CFR 438.408, written notice of appeal disposition must be provided to the member. Notice shall be provided within five (5) business days of resolution. For notice of an expedited resolution, the Contractor must also make reasonable efforts, including a phone call to the member, to provide oral notice. The written notice of the resolution must include the results of the resolution and the date it was completed. For appeals not resolved wholly in favor of the member, the written notice must include the right to request a State fair hearing, including the procedures to do so and the right to request to receive benefits while the hearing is pending, including instructions on how to make the request. This shall also include notice that the member may be held liable for the cost of those benefits if the State hearing upholds the Contractor’s action as set forth in Section 4.12.7.

Appeals Processing Requirements. Members, or providers acting on the member’s behalf, Members shall have sixty (60) calendar days from the date of action adverse benefit determination notice within which to file an appeal. In accordance with 42 CFR 438.402438. 402, a provider, acting on behalf of the member 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 adverse benefit determination are treated as appeals. However, an For oral request for an appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal must be followed by a written request, unless the member or the provider requests an expedited and its resolution. The Contractor shall must acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall 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, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor shall must 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 must 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(c438.408 (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 must 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 must also make a reasonable attempt to give the member prompt oral notice, including a phone call to the member. In accordance with 42 CFR 438.408, written notice of appeal disposition must be provided to the member and, where appropriate, the provider. Notice shall be provided within five (5) business days of resolution. For notice of an expedited resolution, the Contractor must also make reasonable efforts, including a phone call to the member, to provide oral notice. The written notice of the resolution must include the results of the resolution and the date it was completed. For appeals not resolved wholly in favor of the member, the written notice must include the right to request an external grievance procedure (External Review by Independent Review Organization) and State fair hearing, including the procedures to do so and the right to request to receive benefits while the hearing is pending, including instructions on how to make the request. This shall also include notice that the member may be held liable for the cost of those benefits if the State hearing upholds the Contractor’s adverse benefit determination as set forth in Section 4.12.7.

Appeals Processing Requirements. Members, or providers acting on the member’s behalf, Members 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 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 adverse benefit determination are treated as appeals. HoweverFor oral appeals with expedited resolutions the Contractor shall maintain documentation of the oral appeal and its resolution. As of March 1, an 2020, oral request for an appeal must requests no longer need to be followed by a written request, unless the member or the provider requests an expedited resolution. The Contractor shall must acknowledge receipt of each standard appeal within three (3) business days. The Contractor shall 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 ten (1410) calendar business days, pursuant to 42 CFR 438.408(c). If the timeframe is extended, for any extension not requested by the member, the Contractor shall must 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 must 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(c438.408 (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 must 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 must also make a reasonable attempt to give the member prompt oral notice, including a phone call to the member. In accordance with 42 CFR 438.408, written notice of appeal disposition must be provided to the member. Notice shall be provided within five (5) business days of resolution. For notice of an expedited resolution, the Contractor must also make EXHIBIT 1.M SCOPE OF WORK reasonable efforts, including a phone call to the member, to provide oral notice. The written notice of the resolution must include the results of the resolution and the date it was completed. For appeals not resolved wholly in favor of the member, the written notice must include the right to request a State fair hearing, including the procedures to do so and the right to request to receive benefits while the hearing is pending, including instructions on how to make the request. This shall also include notice that the member may be held liable for the cost of those benefits if the State hearing upholds the Contractor’s action as set forth in Section 4.12.7.

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 andard 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. In accordance with 42 CFR 438.408, written notice of appeal disposition shall be provided to the member. Notice shall be provided within five (5) business days of resolution. For notice of an expedited resolution, the Contractor shall also make reasonable efforts, including a phone call to the member, to provide oral notice. The written notice of the resolution must include the results of the resolution and the date it was completed. For appeals not resolved wholly in favor of the member, the written notice shall include the right to request a State fair hearing, including the procedures to do so and the right to request to receive benefits while the hearing is pending, including instructions on how to make the request. This shall also include notice that the member may be held liable for the cost of those benefits if the State hearing upholds the Upon resolution of the member appeal, the Contractor shall notify the State within one (1) business day of the resolution of the appeal and the date the appeal was resolved.

Appeals Processing Requirements. Members, or providers acting on the member’s behalf, shall have sixty thirty-three (6033) 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.