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 must include provisions which address the following:  The Contractor 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. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal.  The Contractor 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 must 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 his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or 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.  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.  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 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).  The Contractor must acknowledge receipt of each grievance and appeal.  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 must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.  The Contractor must ensure that the individuals rendering decisions 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: • An appeal of a denial based on lack of medical necessity; • A grievance regarding denial of expedited resolution of an appeal; and • Any grievance or appeal involving clinical issues.

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following:  The Contractor 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. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal.  The Contractor 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 must 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 his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or 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.  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.  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 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).  The Contractor must acknowledge receipt of each grievance and appeal.  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 must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.  The Contractor must ensure that the individuals rendering decisions 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: •  An appeal of a denial based on lack of medical necessity; •  A grievance regarding denial of expedited resolution of an appeal; and •  Any grievance or appeal involving clinical issues.

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following:  • The Contractor 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. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal.  • The Contractor 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 must 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 his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or 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.  • 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.  • 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 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).  • The Contractor must acknowledge receipt of each grievance and appeal.  • 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).  . A. SCOPE OF WORK • The Contractor must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.  • The Contractor must ensure that the individuals rendering decisions on grievances and appeals were not involved in previous levels of review or decision-making and 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: • An appeal of a denial based on lack of medical necessity; • A grievance regarding denial of expedited resolution of an appeal; and • Any grievance or appeal involving clinical issues.

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following:  The Contractor 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. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal.  The Contractor 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 must 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 his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or 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.  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.  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 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).  The Contractor must acknowledge receipt of each grievance and appeal.  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 must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.  The Contractor must ensure that the individuals rendering decisions 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: •  An appeal of a denial based on lack of medical necessity; • A grievance regarding denial of expedited resolution of an appeal; and • Any grievance or appeal involving clinical issues.;

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following:  • The Contractor 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. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal.  • The Contractor 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 must 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 his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or 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. EXHIBIT 1.  M SCOPE OF WORK • 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.  • 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 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).  • The Contractor must acknowledge receipt of each grievance and appeal.  • 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 must provide members any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.  • The Contractor must ensure that the individuals rendering decisions 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: •  An appeal of a denial based on lack of medical necessity; •  A grievance regarding denial of expedited resolution of an appeal; and •  Any grievance or appeal involving clinical issues.