Common use of Continuation of Services During Appeals Clause in Contracts

Continuation of Services During Appeals. In accordance with 42 CFR 438.420, 438.404(b)(6), and 431.230(b), the Contractor shall continue the Enrollee’s disputed services during the 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 or the Enrollee’s legal guardian or other authorized representative files a request for continuation of disputed services, and files 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.