Common use of Appeals Processing Requirements Clause in Contracts

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 EXHIBIT 1.C SCOPE OF WORK 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 expeditiously as the member’s health condition requires and shall dispose of expedited appeals within forty-eight (48) hours after the Contractor receives notice of the appeal. The Contractor may extend the timeframe for processing an expedited appeal by up to fourteen

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 EXHIBIT 1.C SCOPE OF WORK 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 expeditiously as the member’s health condition requires and shall dispose of expedited appeals within forty-eight (48) hours after the Contractor receives notice of the appeal. The Contractor may extend the timeframe for processing an expedited appeal by up to fourteenfourteen (14) calendar days if the enrollee requests the extension or if the Contractor shows that there is need for additional information and that the delay is in the member’s interest (upon State request) per 42 CFR 438.408(c)(1)(i)- EXHIBIT 1.B. SCOPE OF WORK (iii) and 42 CFR 438.408(b)(3). If the timeframe is extended, for any extension not requested by the member, the Contractor shall 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. In accordance with 42 CFR 438.410, if the Contractor denies the request for an expedited resolution of a member’s appeal, the Contractor 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 must also make a reasonable attempt to give the member prompt oral notice, including a phone call to the member. In compliance with 42 CFR 438.408(b)-(c), the Contractor shall provide the member or representative, the member’s case file free of charge and sufficiently in advance of the resolution timeframe for standard and expedited appeal resolutions in compliance with Indiana law and no longer than thirty (30) calendar days from the day the Contractor receives the appeal. This time period is reduced to 72 hours from the day the Contractor receives an expedited appeal. In accordance with 42 CFR 438.408(d)(2)(ii), written notice of appeal disposition must be provided to the member and, where appropriate, the provider and for notice of an expedited resolution, the Contractor must also make reasonable efforts, including a phone call to the member, to provide oral notice. Notice shall be provided within five (5) business days of resolution. In accordance with 42 CFR 438.408(d)(2)(i), 42 CFR 438.10, and 42 CFR 438.408(e)(1) - (2), 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 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 EXHIBIT 1.C SCOPE OF WORK 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 expeditiously as the member’s health condition requires and shall dispose of expedited appeals within forty-eight (48) hours after the Contractor receives notice of the appeal. The Contractor may extend the timeframe for processing an expedited appeal by up to fourteenfourteen (14) calendar days if the enrollee requests the extension or if the Contractor shows that there is need for additional information and that the delay is in the member’s interest (upon State request) per 42 CFR 438.408(c)(1)(i)- (iii) and 42 CFR 438.408(b)(3). If the timeframe is extended, for any extension not