Common use of Continuation of Benefits Pending Appeal & Reinstatement of Benefits Clause in Contracts

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:  The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  The services were ordered by an authorized provider;  The original period covered by the original authorization has not expired; and  The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:  The member withdraws the request;  Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  The time period or service limits of a previously authorized services has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall pay for those services.

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall must continue the member’s benefits if:   The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;   The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;   The services were ordered by an authorized provider;   The original period covered by the original authorization has not expired; and   The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall must be continued until one of the following occurs:   The member withdraws the request;   Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or   The time period or service limits of a previously authorized services service has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The In accordance with Section 4.12.8, the Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall must authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall must pay for those services.

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:  ▪ The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  ▪ The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  ▪ The services were ordered by an authorized provider;  ▪ The original period covered by the original authorization has not expired; and  ▪ The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:  ▪ The member withdraws the request;  ▪ Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  ▪ The time period or service limits of a previously authorized services has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall pay for those services.

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall must continue the member’s benefits if:  • The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  • The services were ordered by an authorized provider;  • The original period covered by the original authorization has not expired; and  • The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall must be continued until one of the following occurs:  • The member withdraws the request;  • Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  • The time period or service limits of a previously authorized services service has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The In accordance with Section 4.12.8, the Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall must authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall must pay for those services.

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall must continue the member’s benefits if:  : A. SCOPE OF WORK • The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  • The services were ordered by an authorized provider;  • The original period covered by the original authorization has not expired; and  • The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall must be continued until one of the following occurs:  • The member withdraws the requestrequest for appeal;  • Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  • The time period or service limits of a previously authorized services service has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s actionadverse benefit determination, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420CFR 438.420. The In accordance with Section 4.12.8, the Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall must authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall must pay for those services.

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall must continue the member’s benefits if:  • The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;  • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;  ; EXHIBIT 1. M SCOPE OF WORK • The services were ordered by an authorized provider;  • The original period covered by the original authorization has not expired; and  • The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall must be continued until one of the following occurs:  • The member withdraws the request;  • Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or  • The time period or service limits of a previously authorized services service has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The In accordance with Section 4.12.8, the Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall must authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall must pay for those services.

Continuation of Benefits Pending Appeal & Reinstatement of Benefits. In certain member appeals, the Contractor will be required to continue the member’s benefits pending the appeal, in accordance with 42 CFR 438.420. The Contractor shall continue the member’s benefits if:   The member or provider files the appeal within ten (10) days of the Contractor mailing the notice or the intended effective date, whichever is later;   The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;   The services were ordered by an authorized provider;   The original period covered by the original authorization has not expired; and   The member requests extension of benefits. If benefits are continued or reinstated while the appeal is pending, the benefits shall be continued until one of the following occurs:   The member withdraws the request;   Ten (10) days pass after the Contractor has mailed the notice of an adverse decision, unless a State fair hearing and request for continuation of benefits until State hearing is resolved is requested within these ten (10) days; or   The time period or service limits of a previously authorized services has been met. If the final resolution of the appeal is adverse to the member, that is, it upholds the Contractor’s action, the Contractor may recover the cost of the services furnished to the member while the appeal was pending, to the extent that they were furnished solely because of the requirements to maintain benefits in accordance with 42 CFR 431.230 and 42 CFR438.420. The Contractor shall notify the member in advance that costs may be recovered. The Contractor may arrange for the member to pay back any such amounts owed in monthly installments, not to exceed four months. In accordance with 42 CFR 438.424, if the Contractor or State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the Contractor shall authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires. If the Contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the Contractor shall pay for those services.