Common use of Enrollee Appeals Clause in Contracts

Enrollee Appeals. General All Contractors shall utilize and all Enrollees may access the existing Medicare Part D Appeals Process, as described in Appendix F. Consistent with existing rules, Part D Appeals will be automatically forwarded to the IRE if the Contractor misses the applicable adjudication timeframe. The Contractor must maintain written records of all Appeal activities, and notify CMS and MassHealth of all internal Appeals. Integrated/Unified Non-Part D Appeals Process Overview: Notice of Action – In accordance with 42 C.F.R. § 438.404 and 42 C.F.R. § 422.568-572, the Contractor must give the Enrollee written notice of any Adverse Action. Such notice shall be provided at least 10 days in advance of the date of its action, in accordance with 42 C.F.R. §438.404. An Enrollee or a provider acting on behalf of an Enrollee and with the Enrollee’s written consent may appeal the Contractor’s decision to deny, terminate, suspend, or reduce services. In accordance with 42 C.F.R. §438.402 and 42 C.F.R. §422.574, an Enrollee or provider action on behalf of an Enrollee and with the Enrollee’s consent may also appeal the Contractor’s delay in providing or arranging for a Covered Service. Appeal time frames - As more fully detailed below, Enrollees, and/or their providers, or their authorized Appeal representatives will have 60 days to file an Appeal related to coverage and benefits. The Contractor shall acknowledge receipt of each Appeal and notify EOHHS of Board of Hearings Appeals daily. Appeal levels Initial Appeals (first level internal Appeal) will be filed with the Contractor. Subsequent appeals for traditional Medicare A and B services will be automatically forwarded to the Medicare Independent Review Entity (IRE) by the Contractor. Subsequent Appeals for services covered by MassHealth only (e.g. Personal Assistance Services, Behavioral Health Diversionary Services, dental services, LTSS, and MassHealth-covered drugs excluded from Medicare Part D) may be appealed to the MassHealth Board of Hearings (Board of Hearings) after the initial plan-level Appeal has been completed. Appeals for services for which Medicare and Medicaid overlap (including, but not limited to, Home Health, Durable Medical Equipment and skilled therapies, but excluding Part D) will be auto-forwarded to the IRE by the Contractor, and an Enrollee may also file a request for a hearing with the Board of Hearings. If an Appeal is filed with both the IRE and the Board of Hearings, any determination in favor of the Enrollee will bind the Contractor and will require payment by the Contractor for the service or item in question granted in the Enrollee’s favor which is closest to the Enrollee’s relief requested on Appeal.

Enrollee Appeals. General All Contractors shall utilize and all Enrollees may access the existing Medicare Part D Appeals Process, as described in Appendix F. Consistent with existing rules, Part D Appeals will be automatically forwarded to the IRE if the Contractor misses the applicable adjudication timeframe. The Contractor must maintain written records of all Appeal activities, and notify CMS and MassHealth of all internal Appeals. Integrated/Unified Non-Part D Appeals Process Overview: Notice of Action – In accordance with 42 C.F.R. § 438.404 and 42 C.F.R. §§ 422.568-572, the Contractor must give the Enrollee written notice of any Adverse ActionBenefit Determination. Such notice shall be provided at least 10 ten (10) days in advance of the date of its action, in accordance with 42 C.F.R. §§ 438.404. An Enrollee or a provider acting on behalf of an Enrollee and with the Enrollee’s written consent may appeal Appeal the Contractor’s decision to deny, terminate, suspend, or reduce services. In accordance with 42 C.F.R. §§ 438.402 and 42 C.F.R. §§ 422.574, an Enrollee or provider action on behalf of an Enrollee and with the Enrollee’s consent may also appeal Appeal the Contractor’s delay in providing or arranging for a Covered Service. Appeal time frames - As more fully detailed below, Enrollees, and/or their providers, or their authorized Appeal representatives will have 60 sixty (60) days to file an Appeal related to coverage and benefits. The Contractor shall acknowledge receipt of each Appeal and notify EOHHS of Board of Hearings Appeals daily. Appeal levels Initial Appeals (first level internal Appeal) will be filed with the Contractor. Subsequent appeals Appeals for traditional Medicare A and B services will be automatically forwarded to the Medicare Independent Review Entity (IRE) by the Contractor. Subsequent Appeals for services covered by MassHealth only (e.g. Personal Assistance Services, Behavioral Health Diversionary Services, dental services, LTSS, and MassHealth-covered drugs excluded from Medicare Part D) may be appealed Appealed to the MassHealth Board of Hearings (Board of Hearings) after the initial plan-level Appeal has been completed. Appeals for services for which Medicare and Medicaid overlap (including, but not limited to, Home Health, Durable Medical Equipment and skilled therapies, but excluding Part D) will be auto-forwarded to the IRE by the Contractor, and an Enrollee may also file a request for a hearing with the Board of Hearings. If an Appeal is filed with both the IRE and the Board of Hearings, any determination in favor of the Enrollee will bind the Contractor and will require payment by the Contractor for the service or item in question granted in the Enrollee’s favor which is closest to the Enrollee’s relief requested on Appeal. Part D Appeals may not be filed with the Board of Hearings. Appeals related to drugs excluded from Part D that are covered by MassHealth must be filed with the Board of Hearings.