Common use of Grievance Processing Requirements Clause in Contracts

Grievance Processing Requirements. In accordance with 42 CFR 438.402(c)(2)(i) and 42 CFR 438.402(c)(3)(i), members must be allowed to file grievances orally or in writing at any time. Members may file a grievance regarding any matter other than those described in the definition of an adverse benefit determination as described in Section 4.12. Grievances must be filed within sixty (60) calendar days of the occurrence of the matter that is the subject of the grievance. The Contractor must acknowledge receipt of each grievance within three (3) business days. In accordance with 42 CFR 438.408(a) and 42 CFR 438.408(b)(1), the Contractor must make a decision on non-expedited grievances as expeditiously as possible, but not more than thirty (30) calendar days following receipt of the grievance. This timeframe may be extended up to fourteen (14) calendar days if the enrollee requests the extension or the Contractor shows there is need for additional information and the delay is in the member’s interest (upon State request) as required by 42 CFR 438.408(c)(1)(i) - (ii); 438.408(b)(1). In accordance with 42 CFR 438.408(c)(2)(i) - (ii) and 42 CFR 438.408(b)(1), if the timeframe is extended, for any extension not requested by the member, the Contractor shall make reasonable efforts to give the enrollee prompt oral notice of the delay and must give the member written notice of the reason for the delay within two (2) calendar days of the extension, including the reason for the extension and the member’s right to file a grievance if they disagree with the extension. The Contractor shall provide an expedited grievance review if adhering to the resolution timeframe of thirty (30) calendar days would seriously jeopardize the life or health of a member, or the member’s ability to regain maximum function. Expedited grievances must be resolved within forty-eight (48) hours of receipt. If the Contractor denies a request for an expedited review, the Contractor shall transfer the grievance to the standard grievance timeframe per 42 CFR 438.410(c), 42 CFR 438.408(b)(2) and 42 CFR 438.408(c)(2). Further, the Contractor must make a reasonable effort, including a phone call to the member, to provide the member with prompt oral notification of the denial for an expedited review, and shall follow up with a written notice to the member and, where appropriate, the provider within two (2) calendar days.

Grievance Processing Requirements. In accordance with 42 CFR 438.402(c)(2)(i) and 42 CFR 438.402(c)(3)(i), members must be allowed to file grievances orally or in writing at any time. Members may file a grievance regarding any matter other than those described in the definition of an adverse benefit determination as described in Section 4.12. Grievances must be filed within sixty (60) calendar days of the occurrence of the matter that is the subject of the grievance. The Contractor must acknowledge receipt of each grievance within three (3) business days. In accordance with 42 CFR 438.408(a) and 42 CFR 438.408(b)(1), the Contractor must make a decision on non-expedited grievances as expeditiously as possible, but not more than thirty (30) calendar days following receipt of the grievance. This timeframe may be extended up to fourteen (14) calendar days if the enrollee requests the extension or the Contractor shows there is need for additional information and the delay is in the member’s interest (upon State request) as required by 42 CFR 438.408(c)(1)(i) - (ii438.408(c)(1); 438.408(b)(1). In accordance with 42 CFR 438.408(c)(2)(i) - (ii438.408(c)(2) and 42 CFR 438.408(b)(1), if the timeframe is extended, for any extension not requested by the member, the Contractor shall make reasonable efforts to give the enrollee prompt oral notice of the delay and must give the member written notice of the reason for the delay within two (2) calendar days of the extension, including the reason for the extension and the member’s right to file a grievance if they disagree with the extension. The Contractor shall provide an expedited grievance review if adhering to the resolution timeframe of thirty (30) calendar days would seriously jeopardize the life or health of a member, or the member’s ability to regain maximum function. Expedited grievances must be resolved within forty-eight (48) hours of receipt. If the Contractor denies a request for an expedited review, the Contractor shall transfer the grievance to the standard grievance timeframe per 42 CFR 438.410(c), 42 CFR 438.408(b)(2) and 42 CFR 438.408(c)(2). Further, the Contractor must make a reasonable effort, including a phone call to the member, to provide the member with prompt oral notification of the denial for an expedited review, and shall follow up with a written notice to the member and, where appropriate, the provider within two (2) calendar days. The Contractor shall respond in writing to a member within five (5) business days after resolving a grievance or expedited grievance. The notice shall be in a format and language that meets notifications standards per 42 CFR 438.408(d)(1) and 42 CFR 438.10. The resolution includes notice of the member’s right to file an appeal, the process for requesting an appeal, the expedited review options, the right to continue benefits during the appeal (as long as the request complies with timeliness standards), and an explanation that the member may have to pay for care received if an adverse appeal decision is made. The Contractor must make a reasonable effort, including a phone call to the member, to provide oral notification of expedited grievance resolution.