Duration of Continued Disputed Services During Expedited Appeals and Enrollee Responsibility Sample Clauses

Duration of Continued Disputed Services During Expedited Appeals 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) the Aggrieved 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 or the Enrollee’s legal guardian, or other authorized 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 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. (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 Adverse Benefit Determination, the Contractor or Provider may, consistent with the Department’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 8.4.8 of this Contract and in accordance with 42 CFR 431.230(b).
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