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

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