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 withdraws the Appeal or State Fair Hearing request; (2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Aggrieved Person and within that 10 day time period, and the Aggrieved Person 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 Person. (B) If the final resolution of the Appeal or State fair hearing is adverse to the Aggrieved Person, that is, the decision upholds the Contractor’s Adverse Benefit Determination, the Contractor may, consistent with the State’s policy on recoveries and consistent with this Contract, recover the cost of the disputed service furnished to the Enrollee during the pendency of the Appeal or State Fair Hearing to the extent the services were furnished solely in accordance 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 Contractor Contractors shall continue the disputed services until one of the following occurs: (1) the Aggrieved Person withdraws the Appeal or State Fair Hearing requestAppeal; (2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Aggrieved Person Enrollee and within that 10 day time period, and the Aggrieved Person 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 Person; 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 Aggrieved Person, that is, the decision upholds the Contractor’s Adverse Benefit Determination, the Contractor may, or Provider may consistent with the StateDepartment’s usual policy on recoveries and consistent with this Contract, recover the cost of the disputed service furnished to the Enrollee during the pendency of while the Appeal or State Fair Hearing fair hearing was pending to the extent the services they were furnished solely in accordance 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 Contractor Contractors shall continue the disputed services until one of the following occurs: (1) the Aggrieved Person withdraws the Appeal or State Fair Hearing request; (2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Aggrieved Person and within that 10 day time period, and the Aggrieved Person does not request a State fair hearing Fair Hearing with continuation of disputed services until a State fair hearing Fair Hearing decision is reached;; or (3) a State fair hearing Fair Hearing officer issues a hearing decision adverse to the Aggrieved Person. (B) If the final resolution of the Appeal or State fair hearing Fair Hearing is adverse to the Aggrieved Person, that is, the decision upholds the Contractor’s Adverse Benefit Determination, the Contractor may, consistent with the State’s policy on recoveries and consistent with this Contract, recover the cost of the disputed service services furnished to the Enrollee during the pendency of the Appeal or State Fair Hearing to the extent the services were furnished solely in accordance 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 Contractor Contractors shall continue the disputed services until one of the following occurs: (1) the Aggrieved Person withdraws the Appeal or State Fair Hearing requestAppeal; (2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Aggrieved Person Enrollee and within that 10 calendar day time period, and the Aggrieved Person does not request a State fair hearing Fair Hearing with continuation of disputed services until a State fair hearing Fair Hearing decision is reached;; or (3) a State fair hearing Fair Hearing officer issues a hearing decision adverse to the Aggrieved Person. (B) If the final resolution of the Appeal or State fair hearing Fair Hearing is adverse to the Aggrieved PersonEnrollee, that is, the decision upholds the Contractor’s Adverse Benefit Determination, the Contractor or Provider may, consistent with the StateDepartment’s usual policy on recoveries and consistent with this Contract, recover the cost of the disputed service furnished to the Enrollee during the pendency of while the Appeal or State Fair Hearing was pending to the extent the services were furnished solely in accordance 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).