Common use of Duration of Continued Disputed Services and Enrollee Responsibility Clause in Contracts

Duration of Continued Disputed Services and Enrollee Responsibility. (A) If the Contractor continues the Enrollee’s disputed services, the Contractors shall continue the disputed services until one of the following occurs: (1) the Aggrieved Party withdraws the Appeal; (2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Aggrieved Party and within that 10 day time period, and the Aggrieved Party does not request a State fair hearing with continuation of disputed services until a State fair hearing decision is reached; (3) a State fair hearing officer issues a hearing decision adverse to the Aggrieved Party; or (4) the time period of service limits of a previously authorized service has been met. (B) If the final resolution of the Appeal or State fair hearing is adverse to the Enrollee, that is, the decision upholds the Contractor’s Action, the Contractor may recover the cost of the disputed service furnished to the Enrollee while the Appeal or State fair hearing was pending to the extent they were furnished solely because they were furnished according to the requirements found in Article 8.4.8 of this Contract and in accordance with 42 CFR 431.230(b).

Duration of Continued Disputed Services and Enrollee Responsibility. (A) If the Contractor continues the Enrollee’s disputed services, the Contractors shall continue the disputed services until one of the following occurs: (1) the Aggrieved Party Enrollee withdraws the Appeal; (2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Aggrieved Party Enrollee and within that 10 day time period, and the Aggrieved Party Enrollee does not request a State fair hearing with continuation of disputed services until a State fair hearing decision is reached; (3) a State fair hearing officer issues a hearing decision adverse to the Aggrieved PartyEnrollee; or (4) the time period of service limits of a previously authorized service has been met. (B) If the final resolution of the Appeal or State fair hearing is adverse to the Enrollee, that is, the decision upholds the Contractor’s Action, the Contractor may recover the cost of the disputed service furnished to the Enrollee while the Appeal or State fair hearing was pending to the extent they were furnished solely because they were furnished according to the requirements found in Article 8.4.8 of this Contract and in accordance with 42 CFR 431.230(b).