Expedited Resolution of Appeals. The CONTRACTOR shall establish and maintain an expedited review process for Appeals in accordance with 42 C.F.R. § 438.410. The CONTRACTOR shall ensure that the expedited review process is convenient and efficient for the Member. The CONTRACTOR shall resolve the expedited Appeal within seventy-two (72) hours of CONTRACTOR’s receipt of the appeal, per 42 C.F.R. § 438.408(b)(3) and (d)(2). The CONTRACTOR may extend the time frame for an expedited Appeal in accordance with 42 C.F.R. § 438.408(c). For any extension not requested by the Member, the CONTRACTOR shall make reasonable efforts to give the Member prompt oral notice of delay and within two (2) Calendar Days give the Member a written notice of the reason for the decision to extend the time frame and inform the Member of the right to file a grievance if the Member disagrees with the decision to extend the time frame. If the CONTRACTOR denies a request for expedited resolution of an Appeal, the CONTRACTOR shall transfer the Appeal to the time frame for standard resolution and make reasonable efforts to give the Member prompt oral notice of the denial and follow up within two (2) Calendar Days with a written notice. The CONTRACTOR shall inform the Member of the limited time available for expedited reviews to present evidence and allegations in fact or law. The CONTRACTOR shall document in writing all oral requests for expedited resolution and shall maintain the documentation in the case file. The CONTRACTOR must ensure that punitive action is not taken against a Provider who requests an expedited Appeal or supports a Member’s Appeal.
Appears in 4 contracts
Samples: Managed Care Services Agreement, Services Agreement, Managed Care Services Agreement
