Expedited Internal Appeal Process Sample Clauses

Expedited Internal Appeal Process. The Enrollee or their authorized representative has the right to request, orally or in writing, and receive an expedited Appeal decision affecting the Enrollee’s treatment in a time-sensitive situation. The Enrollee must ask for an expedited 72-hour review when the Appeal request is made. The Enrollee need not use the words “expedited” when making the request for an urgent or fast action. The Contractor 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. The Contractor must ensure that punitive action is not taken against a provider who either requests an expedited resolution or supports an Enrollee’s Appeal. If the Contractor decides, based on medical criteria, that the Enrollee’s situation is time-sensitive, or if any physician or other provider of an Enrollee’s services makes the request for the Enrollee or calls or writes in support of the request for an expedited review, the Contractor must issue a decision as expeditiously as the Enrollee’s health requires, but no later than 72 hours after receiving the request. The Contractor may extend this time frame by up to 14 calendar days if the Enrollee requests the extension or if the Contractor justifies the need for additional information and how the extension of time benefits the Enrollee. For any extension not requested by the Enrollee, the Contractor must give the Enrollee written notice of the reason for the delay. The Contractor must make a decision as expeditiously as the Enrollee’s health requires, but no later than the end of any extension period.