Common use of Contractor Grievance and Appeals Policies Clause in Contracts

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals shall include provisions which address the following:  The Contractor shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102, which relates to provider-enrollee communications. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal;  The Contractor shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member;  Throughout the appeals process, the Contractor shall consider the member, representative or estate representative of a deceased member as parties to the appeal;  In accordance with 42 CFR 438.406, provide the member and member representative an opportunity, before and during the appeals process, to examine the member’s case file, including medical records, and any other documents and records considered during the appeals process;  Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing;  Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative the appeal decision. The Contractor’s appeal decision notice shall describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e), which enumerates required content of a notice of resolution;  The Contractor shall notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and sickness insurer);  The Contractor shall provide members any reasonable assistance in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;  The Contractor shall ensure that the individual rendering the decision on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals with appropriate clinical expertise in treating the member’s condition or disease if the decision will be in regard to any of the following: (i) an appeal of a denial based on lack of medical necessity; (ii) a grievance regarding denial of expedited resolution of an appeal; and (iii) any grievance or appeal involving clinical issues.

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals shall must include provisions which address the following:  ▪ The Contractor shall must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102, which relates to provider-enrollee communications. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal;  . ▪ The Contractor shall must not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member;  . ▪ Throughout the appeals process, the Contractor shall must consider the member, representative or estate representative of a deceased member as parties to the appeal;  appeal per 42 CFR 438.406(b)(6). ▪ In accordance with 42 CFR 438.406438.406(b)(5), provide the member and member his representative an opportunity, before and during the appeals process, to examine the member’s case file, including medical records, records and any other documents and or records considered during the appeals process;  Allow . ▪ Xxxxx the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing;  writing per 42 CFR 438.404(b)(4). ▪ Inform the member and member representative of the limited time available to present evidence and allegations of fact or law, in the case of expedited appeal resolution per 42 CFR 438.406(b)(4) and 42 CFR 438.408(b)-(c). ▪ Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative of the appeal decision. The Contractor’s appeal decision notice shall must describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e), which enumerates required content of a notice of resolution;  . ▪ The Contractor shall must acknowledge receipt of each grievance and appeal in accordance with 42 CFR 438.406(b)(1) and 42 CFR 438.228(a). ▪ The Contractor must ensure that decision makers take into account all comments documents, records, and other information submitted by the enrollee or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination per 42 CFR 438.406(b)(2)(iii) and 42 CFR 438.228(a). ▪ The Contractor must notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and sickness insurer);  . ▪ The Contractor shall must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, including but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;  The capability in accordance with 42 CFR 438.406(a) and 42 CFR 438.228(a). ▪ In accordance with 42 CFR 438.228(a), the Contractor shall must ensure that the individual individuals rendering the decision decisions on grievances and appeals were not involved in previous levels of review or decision-making or subordinates of any individual who was involved in a previous level of review or decision-making per 42 CFR 438.406(b)(2)(ii), and in accordance with 42 CFR 438.406(b)(2)(ii), are health care professionals with appropriate clinical expertise (medical, surgical or diagnostic expertise as pertinent to case) in treating the member’s condition or disease if the decision will be in regard to any of the following: (i) an ▪ An appeal of a denial based on lack of medical necessity; (ii) a ▪ A grievance regarding denial of expedited resolution of an appeal; and (iii) any ▪ Any grievance or appeal involving clinical issues. ▪ In accordance with 42 CFR 438.408 and 42 CFR 438.402(c)(1)(i)(A), if the Contractor fails to adhere to notice and timing requirements, the member is deemed to have exhausted the Contractor’s appeals process and the enrollee may initiate a State fair hearing.

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals shall include provisions which address the following:  The Contractor shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102, which relates to provider-provider- enrollee communications. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal;  The Contractor shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member;  Throughout the appeals process, the Contractor shall consider the member, representative or estate representative of a deceased member as parties to the appeal;  In accordance with 42 CFR 438.406, provide the member and member representative an opportunity, before and during the appeals process, to examine the member’s case file, including medical records, and any other documents and records considered during the appeals process;  Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing;  Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative the appeal decision. The Contractor’s appeal decision notice shall describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e), which enumerates required content of a notice of resolution;  The Contractor shall notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-8- 28-16 (if the Contractor is licensed as an accident and sickness insurer);  The Contractor shall provide members any reasonable assistance in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;  The Contractor shall ensure that the individual rendering the decision on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals with appropriate clinical expertise in treating the member’s condition or disease if the decision will be in regard to any of the following: (i) an appeal of a denial based on lack of medical necessity; (ii) a grievance regarding denial of expedited resolution of an appeal; and (iii) any grievance or appeal involving clinical issues.

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals shall include provisions which address the following:  The Contractor shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102, which relates to provider-provider- enrollee communications. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal;  The Contractor shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member;  Throughout the appeals process, the Contractor shall consider the member, representative or estate representative of a deceased member as parties to the appeal;  In accordance with 42 CFR 438.406, provide the member and member representative an opportunity, before and during the appeals process, to examine the member’s case file, including medical records, and any other documents and records considered during the appeals process;  Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing;  Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative the appeal decision. The Contractor’s appeal decision notice shall describe the actions takenaken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e), which enumerates required content of a notice of resolution;  The Contractor shall notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-8- 28-16 (if the Contractor is licensed as an accident and sickness insurer);  The Contractor shall provide members any reasonable assistance in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;  The Contractor shall ensure that the individual rendering the decision on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals with appropriate clinical expertise in treating the member’s s condition or disease if the decision will be in regard to any of the following: (i) an appeal of a denial based on lack of medical necessity; (ii) a grievance regarding denial of expedited resolution of an appeal; and (iii) any grievance or appeal involving clinical issues.