Common use of Continuation of Benefits While the Contractor’s Appeal and the State Fair Hearing Clause in Contracts

Continuation of Benefits While the Contractor’s Appeal and the State Fair Hearing. Are Pending (42 CFR §438.420). i. Timely files mean files for continuation of benefits on or before the later of the following: a. Within 10 calendar days of Contractor sending the notice of adverse benefit determination. b. The intended effective date of the Contractor’s proposed adverse benefit determination. ii. The Contractor shall continue the beneficiary’s benefits if all of the following occur: a. The beneficiary files the request for an appeal timely in accordance with 42 CFR §438.402(c)(1)(ii) and (c)(2)(ii). b. The appeal involves the termination, suspension, or reduction of previously authorized services. c. An authorized provider ordered the services. d. The period covered by the original authorization has not expired. e. The beneficiary timely files for continuation of benefits. iii. At the beneficiary’s request, the Contractor shall continue or reinstate the beneficiary’s benefits while the appeal or state fair hearing is pending, the benefits shall be continued until one of following occurs: a. The beneficiary withdraws the appeal or request for state fair hearing. b. The beneficiary fails to request a state fair hearing and continuation of benefits within 10 calendar days after the Contractor sends the notice of an adverse resolution to the beneficiary’s appeal under 42 CFR §438.408(d)(2). c. A state fair hearing officer issues a hearing decision adverse to the beneficiary. iv. If the final resolution of the appeal or state fair hearing is adverse to the beneficiary, that is, upholds the Contractor’s adverse benefit determination, the Contractor may, consistent with the Department’s usual policy on recoveries under 42 CFR §431.230(b) and as specified in the Contractor’s contract, recover the cost of services furnished to the beneficiary while the appeal and state fair hearing was pending, to the extent that they were furnished solely because of the requirements of this section.

Continuation of Benefits While the Contractor’s Appeal and the State Fair Hearing. Are Pending (42 CFR §438.420). i. Timely files mean files for continuation of benefits on or before the later of the following: a. Within 10 calendar days of Contractor sending the notice of adverse benefit determinationNOABD. b. The intended effective date of the Contractor’s proposed adverse benefit determination. ii. The Contractor shall continue the beneficiary’s benefits if all of the following occur: a. The beneficiary files the request for an appeal timely in accordance with 42 CFR §438.402(c)(1)(ii) and (c)(2)(ii). b. The appeal involves the termination, suspension, or reduction of previously authorized services. c. An authorized provider ordered the services. d. The period covered by the original authorization has not expired. e. The beneficiary timely files for continuation of benefits. iii. At the beneficiary’s request, the Contractor shall continue or reinstate the beneficiary’s benefits while the appeal or state fair hearing is pending, the benefits shall be continued until one of following occurs: a. The beneficiary withdraws the appeal or request for state fair hearing. b. The beneficiary fails to request a state fair hearing and continuation of benefits within 10 calendar days after the Contractor sends the notice of an adverse resolution to the beneficiary’s appeal under 42 CFR §438.408(d)(2). c. A state fair hearing officer issues a hearing decision adverse to the beneficiary. iv. If the final resolution of the appeal or state fair hearing is adverse to the beneficiary, that is, upholds the Contractor’s adverse benefit determination, the Contractor may, consistent with the Department’s usual policy on recoveries under 42 CFR §431.230(b) and as specified in the Contractor’s contract, recover the cost of services furnished to the beneficiary while the appeal and state fair hearing was pending, to the extent that they were furnished solely because of the requirements of this section.

Continuation of Benefits While the Contractor’s Appeal and the State Fair Hearing. Are Pending (42 CFR §438.420). i. Timely files mean files for continuation of benefits on or before the later of the following: a. Within 10 calendar days of Contractor sending the notice of adverse benefit determinationNOABD. b. The intended effective date of the Contractor’s proposed adverse benefit determination. ii. The Contractor shall continue the beneficiary’s benefits if all of the following occur: a. The beneficiary files the request for an appeal timely in accordance with 42 CFR §438.402(c)(1)(ii) and (c)(2)(ii). b. The appeal involves the termination, suspension, or reduction of previously authorized services. c. An authorized provider ordered the services. d. The period covered by the original authorization has not expired. e. The beneficiary timely files for continuation of benefits. iii. At the beneficiary’s request, the Contractor shall continue or reinstate the beneficiary’s benefits while the appeal or state fair hearing is pending, the benefits shall be continued until one of following occurs: a. The beneficiary withdraws the appeal or request for state fair hearing. b. The beneficiary fails to request a state fair hearing and continuation of benefits within 10 calendar days after the Contractor sends the notice of an adverse resolution to the beneficiary’s appeal under 42 CFR §438.408(d)(2). c. A state fair hearing officer issues a hearing decision adverse to the beneficiary. iv. If the final resolution of the appeal or state fair hearing is adverse to the beneficiary, that is, upholds the Contractor’s adverse benefit determination, the Contractor may, consistent with the Department’s usual policy on recoveries under 42 CFR §431.230(b) and as specified in the Contractor’s contractthis Agreement, recover the cost of services furnished to the beneficiary while the appeal and state fair hearing was pending, to the extent that they were furnished solely because of the requirements of this section.