Expedited Appeal Process. The process by which the Appeal of an Action is accelerated because the standard time-frame for resolution of the Appeal could seriously jeopardize the Enrollee's life, health or ability to obtain, maintain or regain maximum function.
Expedited Appeal Process. CHA PACE has an expedited appeal process for situations in which you and/or your caregiver/ family believe that your life, health or ability to regain maximum function would be seriously jeopardized, absent provision of the service in dispute. • CHA PACE will respond to the appeal in the same manner as described in the standard appeal process, as expeditiously as the participant’s health condition requires, but no later than 72 hours after it receives the appeal. • CHA PACE may extend the 72-hour time frame by up to 14 calendar days for either of the following reasons: » You request an extension » CHA PACE justifies to the MassHealth the need for additional information and how the delay is in your best interest In the event that the determination is in your favor, CHA PACE will furnish the disputed service(s) as expeditiously as the participant’s health condition requires.
Expedited Appeal Process. 1. The LME must establish and maintain an expedited review process for appeals for situations in which the LME determines, based on a request from the Enrollee or from a provider on behalf of the Enrollee, that taking the time for a standard resolution could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function.
2. Expedited appeals are just a “special type” of appeals. The LME is required to follow all standard appeal regulations for expedited requests except where differences are specifically noted in the regulation for expedited resolution.
3. The Enrollee may file an expedited appeal either orally or writing. No additional Enrollee follow-up is required.
4. The LME must inform the Enrollee of the limited time available for the Enrollee to present evidence and allegations of fact or law, in person and in writing, in the case of expedited resolution.
5. The LME must resolve each expedited appeal and provide notice, as expeditiously as the Enrollee’s health condition requires, within State-established timeframes not to exceed three (3) working days after the LME receives the appeal.
6. For any extension not requested by the Enrollee, the LME must give the member written notice of the reason for the delay.
7. In addition to written notice, the LME must also make reasonable efforts to provide oral notice.
8. The LME must ensure that punitive action is not taken against a Provider who either requests an expedited resolution or supports an Enrollee’s appeal.
9. If the LME denies a request for expedited resolution of an appeal, it must:
a. Transfer the appeal to the standard timeframe of no longer than forty five (45) days from the day the LME received the appeal,
b. Give the Enrollee prompt oral notice of the denial (make reasonable efforts) and a written notice within two (2) calendar days. The notice should include the information listed under Section D. Service Authorizations and Notices of Action, of this attachment and Notice of Adverse Action included in Section D of this attachment;
Expedited Appeal Process. The process by which the appeal of a Managed Care Plan’s adverse benefit determination is accelerated because the standard timeframe for resolution of the plan appeal could seriously jeopardize the enrollee’s life, health or ability to obtain, maintain or regain maximum function.
Expedited Appeal Process. Action following denial of a request for expedited resolution. Anytime that CONTRACTOR denies a request for an expedited resolution of an appeal, it shall do the following: • Transfer the appeal to the standard timeframe of no longer than forty-five days (45) days from the day the CONTRACTOR receives the appeal with a possible fourteen-day (14) extension; and • Make reasonable efforts to give the enrollee prompt oral notice of the denial, and a written notice within two (2) calendar days.
Expedited Appeal Process. 10.4.1 The Contractor shall establish and maintain an expedited appeal review process for appeals when the Contractor determines, for a request from the enrollee, or the provider indicates, in making the request on the enrollee’s behalf or supporting the enrollee’s request, that taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function.
10.4.2 The Contractor shall make a decision on the enrollee’s request for expedited appeal and provide notice, as expeditiously as the enrollee’s health condition requires, within three (3) calendar days after the Contractor receives the appeal. The Contractor shall also make reasonable efforts to provide oral notice.
10.4.3 The Contractor shall ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal.
10.4.4 If the Contractor denies a request for expedited resolution of an appeal, it shall transfer the appeal to the timeframe for standard resolution and make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice.
10.4.5 The enrollee has a right to file a grievance regarding the Contractors denial of a request for expedited resolution. The Contractor must inform the enrollee of their right to file a grievance in the notice of denial.
Expedited Appeal Process. In situations in which you believe that if a service is not furnished, your life, health, or ability to regain or maintain maximum function could be jeopardized, the appeals process will be expedited if you inform us of this. A decision will be reached on an expedited appeal within 72 hours after the appeal is received. The 72 hour time frame may be extended by up to 14 calendar days if you request the extension or if PACE CNY justifies to the New York State Department of Health the need for additional information and how the delay is in your interest.
Expedited Appeal Process. The Contractor shall accept a request for an expedited appeal either orally or in writing. The Member shall not be required to follow up any request for an expedited appeal. When the Contractor receives a Member’s request for an expedited appeal, the Contractor shall notify that Member of the limited time available for the Member to present evidence and allegations of fact or law, in person or in writing. The Contractor shall make a decision on all expedited appeals within three (3) business days of the request for that expedited appeal and shall make reasonable efforts to provide oral notice of this decision.
4.1.3.14.3.1. The Contractor may extend this timeframe by up to fourteen (14) calendar days if the Member requests the extension or if the Contractor shows that there is need for additional information and that the delay is in the Member’s interest. For any extension not requested by the Member, the Contractor shall give the Member written notice of the reason for the delay. The Contractor shall not take any punitive action against a Member, a Provider, or a Provider supporting a Member’s request, in response to the Member or Provider requesting an expedited appeal. If the Contractor denies a Member’s request for an expedited appeal, then the Contractor shall treat the appeal as a standard appeal and shall notify the Member of the denial of the expedited appeal within two (2) days in writing and shall make reasonable efforts to notify the Member promptly orally.
Expedited Appeal Process. As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum:
1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that taking the time for a standard appeal resolution could seriously jeopardize the beneficiary's life, health or ability to attain, maintain, or regain maximum function.
2) Pursuant to 42 CFR 438.402(b)(3), allow the beneficiary to file the request for an expedited appeal orally without requiring that the request be followed by a written appeal.
3) Pursuant to 42 CFR 438.410(b), ensure that punitive action is not taken against a beneficiary or a provider because they request an expedited appeal or support a beneficiary's request for an expedited appeal.
4) Pursuant to 42 CFR 438.406(b)(4), provide the beneficiary a reasonable opportunity to present evidence, allegations of fact or law, in person as well as in writing and inform the beneficiary of the limited time available for the presentation of evidence.
5) Pursuant to 42 CFR 438.408(b)(3), resolve an expedited appeal, and notify, as expeditiously as the enrollee's health condition requires, the affected parties in writing, no later than three working days after the Contractor receives the appeal. Pursuant to 42 CFR 438.408(c) this timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or the Contractor determines that there is need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210.
6) Pursuant to 42 CFR 438.408(d)(2), provide a beneficiary with a written notice of the expedited appeal disposition and make reasonable efforts to provide oral notice to the beneficiary and/or his or her representative.
7) Pursuant to 42 CFR 438.410(c...
Expedited Appeal Process. If you believe that your life, health or ability to regain or maintain maximum function could be seriously jeopardized, absent the provision of the service in dispute, let us know right away. ElderONE will answer your appeal as expeditiously as your health condition requires but within 72 hours of receipt of the appeal. This is called an expedited appeal. The 72 hour time frame may be extended by up to 14 calendar days if you request the extension or if ElderONE justifies to the New York State Department of Health the need for additional information and that this delay is in your best interest to ensure a thorough review.
