Beneficiary Notice Sample Clauses

Beneficiary Notice. The division of DVHA issuing a service decision with timely and adequate written notice of an adverse action. The notice must explain the following: • The action that DVHA has made or intends to make. • The reasons for the action, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the action. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of DVHA’s adverse action, including the right to request a state fair hearing immediately, including information about the procedures for exercising these rights. • The circumstances under which an appeal process can be expedited and how to request it. • The enrollee’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances, consistent with state policy, under which the enrollee may be required to pay the costs of these services. • When the period of advanced notice is shortened to 5 days if probable recipient fraud has been verified • death of a recipient; • DVHA receives a signed written recipient statement requesting service termination or giving information requiring termination or reduction of services (where he or she understands that this must be the result of supplying that information); • the recipient is admitted to an institution where he or she is ineligible for further services; • when the recipient’s address is unknown and mail directed to him or her has no forwarding address; • when the recipient has been accepted for Medicaid services by another state; • when the recipient’s physician prescribes the change in the level of medical care; • when an adverse determination is made with regard to the preadmission screening requirements for Nursing Facility (NF) admissions on or after January 1, 1989; or the safety or health of individuals in the facility would be endangered, the residents’ health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required by the resident’s urgent medical needs, or a resident has not resided in the nursing facility for 30 days (applies only to adverse actions for NF transfers).