Common use of Attachment to Notice of Action –Written Appeal Request Form Clause in Contracts

Attachment to Notice of Action –Written Appeal Request Form. (A) The Contractor shall develop and include as an attachment to the notice of Action an Appeal Request form that Aggrieved Parties may use as the written Appeal request for standard Appeals. The form may also be used for expedited Appeal requests if the Aggrieved Party chooses to submit a written request for an expedited Appeals resolution, even though an oral request is all that is required. The form shall: (1) Provide a prompt mechanism (through the use of check boxes or other means) for Aggrieved Parties to: (i) request expedited Appeal resolution if they chose to submit a written request for an expedited Appeal resolution; and (ii) request continuation of disputed services, if applicable; (2) Provide a statement that if continuation of disputed services is requested when a previously authorized service is terminated, suspended or reduced, that the Enrollee agrees that the Contractor may recover from the Enrollee the cost of the services furnished while the Appeal is pending if the Appeal decision is adverse to the Enrollee, to the extent that the services were furnished solely because of the requirements of this Contract that are based on federal regulation in 42 CFR 438.420; (3) Summarize the assistance available to the Aggrieved Party may request to complete the Appeal Request form and how to request the assistance; and (4) Include a reminder that if the Aggrieved Party is not requesting an expedited Appeal resolution and the Enrollee files an Appeal orally, that the oral Appeal shall be followed by a written Appeal request within 90 days from the date of the Notice of Action. (B) When the Contractor is required to inform Xxxxxxxxx Parties of their State Fair hearing rights, the Contractor shall not attach its own Appeal Request form but shall, instead, attach the State’s request form for a Medicaid State fair hearing.

Attachment to Notice of Action –Written Appeal Request Form. (A) The Contractor shall develop and include as an attachment to the notice of Action an Appeal Request form that Aggrieved Parties Enrollees may use as the written Appeal request for standard Appeals. The form may also be used for expedited Appeal requests if the Aggrieved Party Enrollee chooses to submit a written request for an expedited Appeals resolution, even though an oral request is all that is required. The form shall: (1) Provide a prompt mechanism (through the use of check boxes or other means) for Aggrieved Parties Enrollees to: (i) request expedited Appeal resolution if they chose to submit a written request for an expedited Appeal resolution; and (ii) request continuation of disputed services, if applicable; (2) Provide a statement that if continuation of disputed services is requested when a previously authorized service is terminated, suspended or reduced, that the Enrollee agrees that the Contractor may recover from the Enrollee the cost of the services furnished while the Appeal is pending if the Appeal decision is adverse to the Enrollee, to the extent that the services were furnished solely because of the requirements of this Contract that are based on federal regulation in 42 CFR 438.420; (3) Summarize the assistance available to the Aggrieved Party Enrollee may request to complete the Appeal Request form and how to request the assistance; and (4) Include a reminder that if the Aggrieved Party Enrollee is not requesting an expedited Appeal resolution and the Enrollee files an Appeal orally, that the oral Appeal shall be followed by a written Appeal request within 90 five working days from the date of the Notice of Actionoral filing. (B) When the Contractor is required to inform Xxxxxxxxx Parties Enrollees or Providers of their State Fair hearing Hearing rights, the Contractor shall not attach its own Appeal Request form but shall, instead, attach the State’s request form for a Medicaid Medicaid/CHIP State fair hearing.