Fair Hearings. 25.1 Enrollee Access To Fair Hearing Process Enrollees may access the fair hearing process in accordance with applicable federal and state laws and regulations. Contractors must abide by and participate in New York State's Fair Hearing Process and comply with determinations made by a fair hearing officer.
25.2 Enrollee Rights to a Fair Hearing Enrollees may request a fair hearing regarding adverse LDSS determinations concerning enrollment, disenrollment and eligibility, and regarding the denial, termination, suspension or reduction of a clinical treatment or other Benefit Package services by the Contractor. For issues related to disputed services, Enrollees must have received an adverse determination from the Contractor or its approved utilization review agent either overriding a recommendation to provide services by a Participating Provider or confirming the decision of a Participating Provider to deny those services. An Enrollee may also seek a fair hearing for a failure by the Contractor to act with reasonable promptness with respect to such services. Reasonable promptness shall mean compliance with the time frames established for review of grievances and utilization review in Sections 44 and 49 of the Public Health Law.
Fair Hearings. Pursuant to 18 NYCRR Part 358, the Department will notify eligible applicants for, or recipients of, services of their right to a fair hearing to appeal the denial, reduction or termination of a service, or the failure of the Department to act upon an application within the appropriate time frames. The Department also will inform applicants for or recipients of preventive, adoption services or kinship guardianship assistance how to make and submit a fair hearing request. The Department will provide the Agency with copies of the fair hearing decision it receives from the State of New York. The Agency, upon the request of the Department, must participate in fair hearings and any appeals thereof as witnesses when necessary for a determination of the issues.
Fair Hearings. 7.1.1 When a unit member is required to participate in a fair hearing or other due process procedure, the District shall provide the unit member with release time without loss of compensation. If the fair hearing is held after regular hours of employment, unit members shall receive their hourly rates of pay.
7.1.2 Counsel retained to represent the District in any such hearing may consult with the unit member regarding preparation for the hearing.
Fair Hearings. The Contractor understands that all applicants for services hereunder, as well as individuals declared ineligible have a right to a fair hearing regarding that determination. The Contractor hereby covenants and agrees that all applicants for services shall be permitted to fill out an application form and that each applicant or re-applicant shall be informed of his/her right to a fair hearing in accordance with Department regulations.
Fair Hearings. The PASSE must participate in the Fair Hearing process and comply with the Arkansas Administrative Procedures Act, Ark. Code Xxx. §§ 25- 15-201 et seq.
Fair Hearings i. All enrollees must have access to the state fair hearing process as required by 42 CFR §431 Subpart E. In addition, the requirements governing MCO appeals and grievances in 42 CFR §438 Subpart F shall apply.
ii. The MCO contract shall specify whether enrollees must exhaust the MCO’s internal appeals process before exercising their right to a state fair hearing.
iii. The MCO contract shall require the MCO to make whatever reasonable accommodations are necessary to ensure that enrollees have a meaningful opportunity to exercise their appeal and grievance rights.
Fair Hearings. 24.1 Enrollee Access to Fair Hearing Process Enrollees in the Contractor's Medicaid Advantage Product may access the fair hearing process related to services determined by the Contractor to be a Medicaid only benefit or services determined by the Contractor to be a benefit under both Medicare and Medicaid in accordance with applicable federal and state laws and regulations. The Contractor must abide by and participate in New York State's Fair Hearing Process and comply with determinations made by a fair hearing officer.
24.2 Enrollee Rights to a Fair Hearing Enrollees in the Contractor's Medicaid Advantage Product may request a fair hearing regarding adverse LDSS determinations concerning enrollment, disenrollment and eligibility, and regarding the denial, termination, suspension or reduction of a service determined by the Contractor to be a Medicaid only benefit or a benefit under both Medicare and Medicaid. For issues related to disputed services, Enrollees must have received an adverse determination from the Contractor or its approved utilization review agent either overriding a recommendation to provide services by a Participating Provider or confirming the decision of a Participating Provider to deny those services. An Enrollee may also seek a fair hearing for a failure by the Contractor to act with reasonable promptness with respect to such services. Reasonable promptness shall mean compliance with the time frames established for review of grievances and utilization review in Sections 44 and 49 of the Public Health Law, the grievance system requirements of 42 CFR Part 438 and Appendix F of this Agreement.
Fair Hearings. 10.4. 1 Only the Individual or the Individual's Authorized Representative may file a request for a Fair Hearing.
10.4.2 If an Individual does not agree with GCBH's resolution of the Grievance, the Individual may file a request for a Fair Hearing within the following time frames: GCBH Agreement No. TTSS16-00
1 0.4.2. 1 For Fair Hearings regarding a standard service, within ninety (90) calendar days of the date on GCBH's mailing of the Notice of Resolution of the Appeal.
Fair Hearings. C.14.4.1 The Contractor shall notify the Enrollee or the Enrollee's designee of the right to a fair hearing with a District hearing officer, each time notification of an adverse decision on a complaint, grievance, or appeal is sent to an Enrollee or the Enrollee's designee.
C.14.4.2 The Contractor shall submit all documents regarding the Plan's action and the Enrollee's dispute to MAA no later than five (5) working days from the date the Contractor receives notice from the District that a fair hearing request has been filed if an Enrollee requests a fair hearing.
C.14.4.3 An Enrollee may request a fair hearing before, during, or after a Contractor's grievance process. However, an -------------------------------------------------------------------------------- CONTRACT NO.: P0HC-2002-D-0003 119 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Enrollee is allowed no more than ninety (90) days from the date notice of action is mailed to request a hearing.
C.14.4.4 Pending the decision from the fair hearing, the Contractor shall continue to furnish the item or service at the level and in the amount, scope, and duration that item or service was provided to the Enrollee prior to notification of the Contractor's determination.
C.14.4.5 The Contractor shall assist the enrollee with filing of any request for a fair hearing and send a copy of the request filed to the enrollee's home address.
Fair Hearings. The Contractor shall represent the Contractor’s position in fair hearings (as defined in Title 9,CCR, Section dealing with beneficiaries’ appeals of denials, modifications, deferrals or terminations of covered services. The Contractor shall carry out the final decisions of the fair hearing process with respect to issues within the scope of the Contractor’s responsibilities under this contract. Nothing in this section is intended to prevent the Contractor from pursuing any options available for appealing a fair hearing decision. U. Crosswalk between Provider System The Contractor shall comply with Title 9, CCR, Section 1840.304 when submitting claims for federal financial participation for services billed by individual or group providers using service codes from the Health Care Financing Administration’s Common Procedure Coding System (HCPCS). At such time as the table currently included in Section 1840.304 is deleted from this section, the Contractor shall follow the table issued by the Department as a DMH Information Notice.