Common use of Format and Content of Notice of Appeal Resolution Clause in Contracts

Format and Content of Notice of Appeal Resolution. (A) The Contractor shall provide written Notice of Appeal Resolution to the affected parties. The written Notice of Appeal Resolution shall include the following: (1) the results of the Appeal resolution process and the date it was completed; and (2) for Appeals not resolved wholly in favor of the Enrollee, the Contractor shall include the following in the written Notice of Appeal Resolution: (i) the right to request a State fair hearing and how to do so; (ii) the right to request continuation of disputed services if the Appeal decision is to terminate, suspend or reduce a previously authorized course of treatment that was ordered by an authorized Provider and the original period covered by the original authorization has not expired; (3) how to request continuation of disputed services; (4) a statement that the Enrollee may be liable for the cost of disputed services provided if the State fair hearing decision upholds the Contractor’s Action; (5) the time frame for requesting a State fair hearing when continuation of disputed services is not requested and when continuation of disputed services is requested; and (6) as applicable, a copy of either: (i) the standard request form for a State fair hearing; or (ii) the request form for an expedited State fair hearing that the Enrollee must complete and submit to the Department to request a State fair hearing and continuation of disputed services; or (iii) the standard request form for an expedited State fair hearing if the Enrollee has an expedited Appeal.

Format and Content of Notice of Appeal Resolution. (A) The Contractor shall provide written Notice of Appeal Resolution to the affected parties. The written Notice of Appeal Resolution shall include the following: (1) the results of the Appeal resolution process and the date it was completed; and (2) for Appeals not resolved wholly in favor of the EnrolleeAggrieved Person, the Contractor shall include the following in the written Notice of Appeal Resolution: (i) the right to request a State fair hearing and how to do so; (ii) the right to request continuation of disputed services if the Appeal decision is to terminate, suspend or reduce a previously authorized course of treatment that was ordered by an authorized Provider and the original period covered by the original authorization has not expired; (3) how to request continuation of disputed services; (4) a statement that the Enrollee may be liable for the cost of disputed services provided if the State fair hearing decision upholds the Contractor’s ActionAdverse Benefit Determination; (5) the time frame for requesting a State fair hearing Fair Hearing when continuation of disputed services is not requested and when continuation of disputed services is requested; and (6) as applicable, a copy of either: (i) the standard State Fair Hearing request form for a State fair hearing; or (ii) the request form for an expedited State fair hearing that the Enrollee must complete and submit to the Department to request a State fair hearing and continuation of disputed services; or (iii) the standard request form for an expedited State fair hearing if the Enrollee has an expedited Appealform.