Common use of Coverage Determinations and Appeals Call Center Requirements Clause in Contracts

Coverage Determinations and Appeals Call Center Requirements. The Contractor must operate a toll‑free call center with live customer service representatives available to respond to providers or Enrollees for information related to requests for coverage under Medicare or Medicaid, and Medicare and Medicaid Appeals (including requests for Medicare exceptions and prior authorizations). The Contractor is required to provide immediate access to requests for Medicare and Medicaid covered benefits and services, including Medicare coverage determinations and redeterminations, via its toll‑free call centers. The call centers must operate during normal business hours as specified in the Medicare Communications and Marketing Guidelines, and the Medicare‑Medicaid marketing guidance. The Contractor must accept requests for Medicare or Medicaid coverage, including Medicare coverage determinations /redeterminations, outside of normal business hours, but is not required to have live customer service representatives available to accept such requests outside normal business hours. Voicemail may be used outside of normal business hours provided the message: Indicates that the mailbox is secure; Lists the information that must be provided so the case can be worked (e.g., provider identification, beneficiary identification, type of request (coverage determination or Appeal), physician support for an exception request, and whether the member is making an expedited or standard request); For coverage determination calls (including exceptions requests), articulates and follows a process for resolution within twenty‑four (24) hours of call for expedited requests and seventy‑two (72) hours for standard requests; and For Appeals calls, information articulates the process information needed and provide for a resolution within seventy‑two (72) hours for expedited Appeal requests and thirty (30) calendar days for standard Appeal requests.

Coverage Determinations and Appeals Call Center Requirements. The Contractor must operate a toll‑free toll-free call center with live customer service representatives available to respond to providers or Enrollees for information related to requests for coverage under Medicare or Medicaid, and Medicare and Medicaid Appeals (including requests for Medicare exceptions and prior authorizations). The Contractor is required to provide immediate access to requests for Medicare and Medicaid covered benefits and services, including Medicare coverage determinations and redeterminations, via its toll‑free toll-free call centers. The call centers must operate during normal business hours as specified in the Medicare Communications and Marketing Guidelines, and the Medicare‑Medicaid Medicare- Medicaid marketing guidance. The Contractor must accept requests for Medicare or Medicaid coverage, including Medicare coverage determinations /redeterminations, outside of normal business hours, but is not required to have live customer service representatives available to accept such requests outside normal business hours. Voicemail may be used outside of normal business hours provided the message: Indicates that the mailbox is secure; Lists the information that must be provided so the case can be worked (e.g., provider identification, beneficiary identification, type of request (coverage determination or Appeal), physician support for an exception request, and whether the member is making an expedited or standard request); For coverage determination calls (including exceptions requests), articulates and follows a process for resolution within twenty‑four twenty-four (24) hours of call for expedited requests and seventy‑two seventy-two (72) hours for standard requests; and For Appeals calls, information articulates the process information needed and provide for a resolution within seventy‑two seventy-two (72) hours for expedited Appeal requests and thirty (30) calendar days for standard Appeal requests.. Consumer Advisory Board The Contractor shall establish a Consumer advisory board or include MMP Consumers on a pre-existing governance board that will provide regular feedback to the Contractor‘s governing board on issues of Demonstration management and Enrollee care. The Contractor shall ensure that the Consumer advisory board:

Coverage Determinations and Appeals Call Center Requirements. 1. The Contractor must operate a toll‑free toll-free call center with live customer service representatives available to respond to providers or Enrollees for information related to requests for coverage under Medicare or Medicaid, and Medicare and Medicaid Appeals (including requests for Medicare exceptions and prior authorizations). The Contractor is required to provide immediate access to requests for Medicare and Medicaid covered benefits and services, including Medicare coverage determinations and redeterminations, via its toll‑free toll-free call centers. The call centers must operate during normal business hours as specified in the Medicare Communications and Marketing Guidelinesnever less than from 8:00 a.m. to 6:00 p.m., and the Medicare‑Medicaid marketing guidanceMonday through Friday. The Contractor must accept requests for Medicare or Medicaid coverage, including Medicare coverage determinations /redeterminations, outside of normal business hours, but is not required to have live customer service representatives available to accept such requests outside normal business hours. Voicemail may be used outside of normal business hours provided the message: Indicates that the mailbox is secure; Lists the information that must be provided so the case can be worked (e.g., provider identification, beneficiary identification, type of request (coverage determination or Appeal), physician support for an exception request, and whether the member is making an expedited or standard request); For coverage determination calls (including exceptions requests), articulates and follows a process for resolution within twenty‑four twenty-four (24) hours of call for expedited requests and seventy‑two seventy-two (72) hours for standard requests; and For Appeals calls, information articulates the process information needed and provide for a resolution within seventy‑two seventy-two (72) hours for expedited Appeal requests and thirty (30) 30 calendar days for standard Appeal requests.

Coverage Determinations and Appeals Call Center Requirements. 1. The Contractor must operate a toll‑free toll-free call center with live customer service representatives available to respond to providers or Enrollees for information related to requests for coverage under Medicare or Medicaid, and Medicare and Medicaid Appeals (including requests for Medicare exceptions and prior authorizations). The Contractor is required to provide immediate access to requests for Medicare and Medicaid covered benefits and services, including Medicare coverage determinations and redeterminations, via its toll‑free toll-free call centers. The call centers must operate during normal business hours as specified in the Medicare Communications and Marketing Guidelines, the Medicare-Medicaid marketing guidance and the Medicare‑Medicaid marketing Massachusetts state specific Marketing guidance. The Contractor must accept requests for Medicare or Medicaid coverage, including Medicare coverage determinations /redeterminations, outside of normal business hours, but is not required to have live customer service representatives available to accept such requests outside normal business hours. Voicemail may be used outside of normal business hours provided the message: Indicates that the mailbox is secure; Lists the information that must be provided so the case can be worked (e.g., provider identification, beneficiary identification, type of request (coverage determination or Appeal), physician support for an exception request, and whether the member is making an expedited or standard request); For coverage determination calls (including exceptions requests), articulates and follows a process for resolution within twenty‑four twenty-four (24) hours of call for expedited requests and seventy‑two seventy-two (72) hours for standard requests; and For Appeals calls, information articulates the process information needed and provide for a resolution within seventy‑two seventy-two (72) hours for expedited Appeal requests and thirty (30) 30 calendar days for standard Appeal requests.