Authority to File. i. A beneficiary may file a grievance and request an appeal with the Contractor. A beneficiary may request a state fair hearing after receiving notice under 42 CFR §438.408 that the adverse benefit determination is upheld. 1. In the case that the Contractor fails to adhere to the notice and timing requirements in 42 CFR §438.408, the beneficiary is deemed to have exhausted the Contractor’s appeals process. The beneficiary may initiate a state fair hearing. 2. The Department may offer and arrange for an external medical review if the following conditions are met. a. The review shall be at the beneficiary’s option and shall not be required before, or used as a deterrent to, proceeding to the state fair hearing. b. The review shall be independent of both the Department and the Contractor. c. The review shall be offered without any cost to the beneficiary. d. The review shall not extend any of the timeframes specified in 42 CFR §438.408 and shall not disrupt the continuation of benefits in 42 CFR §438.420. ii. With the written consent of the beneficiary, a provider or an authorized representative may request an appeal or file a grievance, or request a state fair hearing, on behalf of a beneficiary, with the exception that providers cannot request continuation of benefits as specified in 42 CFR §438.420(b)(5).
Appears in 3 contracts
Samples: Behavioral Health Services Agreement, Intergovernmental Agreement, Intergovernmental Agreement
Authority to File. i. A beneficiary may file a grievance and request an appeal with the Contractor. A beneficiary may request a state fair hearing after receiving notice under 42 CFR §438.408 that the adverse benefit determination is upheld.
1. In the case that the Contractor fails to adhere to the notice and timing requirements in 42 CFR §438.408, the beneficiary is deemed to have exhausted the Contractor’s appeals process. The beneficiary may initiate a state fair hearing.
2. The Department may offer and arrange for an external medical review if the following conditions are met.
a. The review shall be at the beneficiary’s option and shall not be required before, or used as a deterrent to, proceeding to the state fair hearing.
b. The review shall be independent of both the Department and the Contractor.
c. The review shall be offered without any cost to the beneficiary.
d. The review shall not extend any of the timeframes specified in 42 CFR §438.408 and shall not disrupt the continuation of benefits in 42 CFR §438.420.
ii. With the written consent of the beneficiary, a provider or an authorized representative may request an appeal or file a grievance, or request a state fair hearing, on behalf of a beneficiary, with the exception that providers cannot request continuation of benefits as specified in 42 CFR §438.420(b)(5).
Appears in 1 contract
