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 Contractor shall continue the disputed services until one of the following occurs: (1) the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative, withdraws the Appeal or State Fair Hearing request; (2) the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative, fails to request a State Fair Hearing within 10 calendar days after the Contractor sends the notice of an adverse resolution; (3) the Enrollee, the Enrollee's legal guardian, or other authorized representative, fails to submit to the State Fair Hearing office, within 10 calendar days after the Contractor sends the notice of an adverse resolution, a written request for continuation of the disputed services during the State Fair Hearing; or (4) a State Fair Hearing officer issues a hearing decision adverse to the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative. (B) If the final resolution of the Appeal or State Fair Hearing is adverse to the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative, that is, the decision upholds the Contractor’s Adverse Benefit Determination, the Contractor or Provider may, consistent with the State’s policy on recoveries and consistent with this Contract, recover the cost of the disputed services furnished to the Enrollee while the Appeal or State Fair Hearing was pending to the extent the services were furnished solely because of the requirements found in Article 8.3.6 of this attachment 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 Contractor shall continue the disputed services until one of the following occurs: (1) the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative, Person withdraws the Appeal or State Fair Hearing request; (2) the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative, Person fails to request a State Fair Hearing within 10 calendar days after the Contractor sends the notice of an adverse resolution; (3) the Enrollee, Enrollee or the Enrollee's ’s legal guardian, or other authorized representative, representative that is not the Provider fails to submit to the State Fair Hearing office, within 10 calendar days after the Contractor sends the notice of an adverse resolution, a written request for continuation of the disputed services during the State Fair Hearing; or (4) a State Fair Hearing officer issues a hearing decision adverse to the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative. (B) If the final resolution of the Appeal or State Fair Hearing is adverse to the Aggrieved Person, the Enrollee's legal guardian, or other authorized representative, that is, the decision upholds the Contractor’s Adverse Benefit Determination, the Contractor or Provider may, consistent with the State’s policy on recoveries and consistent with this Contract, recover the cost of the disputed services furnished to the Enrollee while the Appeal or State Fair Hearing was pending pending, to the extent the services were furnished solely because of the requirements found in Article 8.3.6 of this attachment Contract and in accordance with 42 CFR § 431.230(b).