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 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