Continuation of Disputed Services During Expedited Appeals Sample Clauses

Continuation of Disputed Services During Expedited Appeals. The Contractor shall continue the Enrollee’s disputed services during the expedited Appeal if: (1) the Adverse Benefit Determination being appealed is to reduce, suspend or terminate a previously authorized course of treatment; (2) the services were ordered by an authorized Provider; (3) the period covered by the original authorization has not expired; (4) the Enrollee or the Enrollee’s legal guardian or other authorized representative files a request for continuation of disputed services, and files timely, which means filing the request on or before the later of the following: (i) within 10 calendar days of the Contractor sending the Notice of Adverse Benefit Determination; or (ii) by the intended effective date of the Contractor’s proposed Adverse Benefit Determination.
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Continuation of Disputed Services During Expedited Appeals. In accordance with 42 CFR § 438.420, 42 CFR § 438.404(b)(6), and 42 CFR § 431.230(b), the Contractor shall continue the Enrollee’s disputed services during the expedited Appeal if: (1) the Adverse Benefit Determination is to reduce, suspend, or terminate a previously authorized course of treatment; (2) the services were ordered by an authorized Provider; (3) the period covered by the original authorization has not expired; and (4) the Enrollee files a request for continuation of disputed services timely, which means filing on or before the later of the following: (i) within 10 calendar days of the Contractor sending the Notice of Adverse Benefit Determination; or (ii) by the intended effective date of the Contractor’s proposed Adverse Benefit Determination.
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Related to Continuation of Disputed Services During Expedited Appeals

  • Negotiation; Alternative Dispute Resolution The Parties will attempt in good faith to resolve any dispute or controversy arising out of or relating to the performance of services under this Agreement. If the Parties are unable to resolve the dispute, then, pursuant to San Francisco Administrative Code Section 21.36, Contractor may submit to the Contracting Officer a written request for administrative review and documentation of the Contractor's claim(s). Upon such request, the Contracting Officer shall promptly issue an administrative decision in writing, stating the reasons for the action taken and informing the Contractor of its right to judicial review. If agreed by both Parties in writing, disputes may be resolved by a mutually agreed-upon alternative dispute resolution process. If the parties do not mutually agree to an alternative dispute resolution process or such efforts do not resolve the dispute, then either Party may pursue any remedy available under California law. The status of any dispute or controversy notwithstanding, Contractor shall proceed diligently with the performance of its obligations under this Agreement in accordance with the Agreement and the written directions of the City. Neither Party will be entitled to legal fees or costs for matters resolved under this section.