Common use of Grievances and Appeals Clause in Contracts

Grievances and Appeals. ‌ Insurer shall have a Grievance and Appeal system in place for Enrollees in compliance with 42 CFR 457.1260. The Grievance and Appeal system shall be the same for Title XXI Enrollees and Full-pay Plan Enrollees. Insurer shall establish and maintain policies and procedures for the Grievance and Appeal system, including procedures for expedited Appeals. Insurer shall provide its Grievance and Appeal policies and procedures to FHKC by the date established in the approved implementation plan and at least sixty (60) Calendar Days prior to any proposed changes. The initial policy and procedures and any subsequent changes are subject to approval by FHKC. Insurer shall provide its Grievance and Appeal policies and procedures to Providers and Subcontractors when Insurer engages with such entities or individuals and after any approved changes. Insurer shall ensure individuals making decisions about Grievances and Appeals: a. Were not involved in any previous level of review or decision-making and are not the subordinate of any such individual; b. Have the appropriate clinical expertise in treating the Enrollee’s condition or disease when: i. An Appeal is based on lack of Medical Necessity; ii. A Grievance is about the denial of an expedited resolution of an Appeal; and iii. A Grievance or Appeal involves clinical issues. c. Take all comments, documents, records, and other information submitted by the Enrollee or Enrollee’s representative into account without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. Insurer shall maintain a record of all Grievances and Appeals that includes the following information for each Grievance and Appeal: a. Date received; b. Date of each review or review meeting, as applicable; c. Enrollee name; d. Nature or general description of the reason for the Grievance or Appeal; e. Disposition of each level of the Grievance and Appeal process, as applicable; f. Date of resolution at each level, as applicable; and g. Documents relevant to each Grievance and Appeal. Insurer shall accurately maintain these records in a manner accessible to FHKC and, upon request, CMS. Insurer shall provide FHKC with a quarterly Grievances and Appeals report. The Grievances and Appeals report shall include: a. A summary analysis of the Grievances and Appeals that includes: i. Appeal response timeliness as a percentage of Appeals in the reporting quarter that were closed timely. Appeals closed in the quarter includes Appeals that were received in a different quarter and closed in the reporting quarter. ii. Grievance response timeliness as a percentage of Grievances in the reporting quarter that were closed timely. Grievances closed in the quarter includes Grievances that were received in a different quarter and closed in the reporting quarter. b. Line item records of Grievances and Appeals received in the quarter that includes: i. The date received; ii. Identification as a Grievance or an Appeal; iii. Nature or general description of the reason for the Grievance or Appeal; iv. The disposition, as applicable; v. The date of the disposition, as applicable; vi. If a Subcontractor handles the Grievance or Appeal, the name of the Subcontractor responsible; and vii. An indicator showing whether the Grievance or Appeal is for a Title XXI Enrollee or a Full-pay Plan Enrollee. c. Line item records of Grievances and Appeals closed in the quarter that includes: i. The date received; ii. Identification as a Grievance or an Appeal; iii. Nature or general description of the reason for the Grievance or Appeal; iv. The disposition; v. The date of the disposition; vi. If a Subcontractor handles the Grievance or Appeal, the name of the Subcontractor responsible; and vii. An indicator showing whether the Grievance or Appeal is for a Title XXI Enrollee or a Full-pay Plan Enrollee. Insurer shall provide an annual summary analysis Grievance and Appeals report that includes: a. Appeal response timeliness as a percentage of Appeals in the reporting Contract Year that were closed timely. Appeals closed in the Contract Year includes Appeals that were received in a different Contract Year for this Contract and closed in the reporting Contract Year. b. Grievance response timeliness as a percentage of Grievances in the reporting Contract Year that were closed timely. Grievances closed in the Contract Year includes Grievances that were received in a different Contract Year for this Contract and closed in the reporting Contract Year.

Grievances and Appeals. ‌ Insurer shall have a Grievance and Appeal system in place for Enrollees in compliance with 42 CFR 457.1260. The Grievance and Appeal system shall be the same for Title XXI Enrollees and Full-pay Plan Enrollees. Insurer shall establish and maintain policies and procedures for the Grievance and Appeal system, including procedures for expedited Appeals. Insurer shall provide its Grievance and Appeal policies and procedures to FHKC by the date established in the approved implementation plan and at least sixty (60) Calendar Days prior to any proposed changes. The initial policy and procedures and any subsequent changes are subject to approval by FHKC. Insurer shall provide its Grievance and Appeal policies and procedures to Providers and Subcontractors when Insurer engages enters into a written agreement with such entities or individuals and after any approved changes. Insurer shall ensure individuals making decisions about Grievances and Appeals: a. Were not involved in any previous level of review or decision-making and are not the subordinate of any such individual; b. Have the appropriate clinical expertise in treating the Enrollee’s condition or disease when: i. An Appeal is based on lack of Medical Necessity; ii. A Grievance is about the denial of an expedited resolution of an Appeal; and iii. A Grievance or Appeal involves clinical issues. c. Take all comments, documents, records, records and other information submitted by the Enrollee or Enrollee’s representative into account without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. Insurer shall maintain a record of all Grievances and Appeals that includes the following information for each Grievance and Appeal: a. Date received; b. Date of each review or review meeting, as applicable; c. Enrollee name; d. Nature or general description of the reason for the Grievance or Appeal; e. Disposition of each level of the Grievance and Appeal process, as applicable; f. Date of resolution at each level, as applicable; and g. Documents relevant to each Grievance and Appeal. Insurer shall accurately maintain these records in a manner accessible to FHKC and, upon request, CMS. Insurer shall provide FHKC with a quarterly Grievances and Appeals report. The Grievances and Appeals report shall include: a. A summary analysis of the Grievances and Appeals that includes: i. Appeal response timeliness as a percentage of Appeals in the reporting quarter that were closed timely. Appeals closed in the quarter includes Appeals that were received in a different quarter and closed in the reporting quarter. ii. Grievance response timeliness as a percentage of Grievances in the reporting quarter that were closed timely. Grievances closed in the quarter includes Grievances that were received in a different quarter and closed in the reporting quarter. b. Line item records of Grievances and Appeals received in the quarter that includes: i. The date received; ii. Identification as a Grievance or an Appeal; iii. Nature or general description of the reason for the Grievance or Appeal; iv. The disposition, as applicable; v. The date of the disposition, as applicable; vi. If a Subcontractor handles the Grievance or Appeal, the name of the Subcontractor responsible; and vii. An indicator showing whether the Grievance or Appeal is for a Title XXI Enrollee or a Full-pay Plan Enrollee. c. Line item records of Grievances and Appeals closed in the quarter that includes: i. The date received; ii. Identification as a Grievance or an Appeal; iii. Nature or general description of the reason for the Grievance or Appeal; iv. The disposition; v. The date of the disposition; vi. If a Subcontractor handles the Grievance or Appeal, the name of the Subcontractor responsible; and vii. An indicator showing whether the Grievance or Appeal is for a Title XXI Enrollee or a Full-pay Plan Enrollee. Insurer shall provide an annual summary analysis Grievance and Appeals report that includes: a. Appeal response timeliness as a percentage of Appeals in the reporting Contract Year that were closed timely. Appeals closed in the Contract Year includes Appeals that were received in a different Contract Year for this Contract and closed in the reporting Contract Year. b. Grievance response timeliness as a percentage of Grievances in the reporting Contract Year that were closed timely. Grievances closed in the Contract Year includes Grievances that were received in a different Contract Year for this Contract and closed in the reporting Contract Year.

Grievances and Appeals. ‌ Insurer shall have a Grievance and Appeal system in place for Enrollees in compliance with 42 CFR 457.1260. The Grievance and Appeal system shall be the same for Title XXI Enrollees and Full-pay Plan Enrollees. Insurer shall establish and maintain policies and procedures for the Grievance and Appeal system, including procedures for expedited Appeals. Insurer shall provide its Grievance and Appeal policies and procedures to FHKC by the date established in the approved implementation plan and at least sixty (60) Calendar Days prior to any proposed changes. The initial policy and procedures and any subsequent changes are subject to approval by FHKC. Insurer shall provide its Grievance and Appeal policies and procedures to Providers and Subcontractors when Insurer engages with such entities or individuals and after any approved changes. Insurer shall ensure individuals making decisions about Grievances and Appeals: a. : Were not involved in any previous level of review or decision-making and are not the subordinate of any such individual; b. ; Have the appropriate clinical expertise in treating the Enrollee’s condition or disease when: i. : An Appeal is based on lack of Medical Necessity; ii. ; A Grievance is about the denial of an expedited resolution of an Appeal; and iii. A Grievance or Appeal involves clinical issues. c. . Take all comments, documents, records, and other information submitted by the Enrollee or Enrollee’s representative into account without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. Insurer shall maintain a record of all Grievances and Appeals that includes the following information for each Grievance and Appeal: a. : Date received; b. ; Date of each review or review meeting, as applicable; c. ; Enrollee name; d. ; Nature or general description of the reason for the Grievance or Appeal; e. ; Disposition of each level of the Grievance and Appeal process, as applicable; f. ; Date of resolution at each level, as applicable; and g. and Documents relevant to each Grievance and Appeal. Insurer shall accurately maintain these records in a manner accessible to FHKC and, upon request, CMS. Insurer shall provide FHKC with a quarterly Grievances and Appeals report. The Grievances and Appeals report shall include: a. : A summary analysis of the Grievances and Appeals that includes: i. : Appeal response timeliness as a percentage of Appeals in the reporting quarter that were closed timely. Appeals closed in the quarter includes Appeals that were received in a different quarter and closed in the reporting quarter. ii. Grievance response timeliness as a percentage of Grievances in the reporting quarter that were closed timely. Grievances closed in the quarter includes Grievances that were received in a different quarter and closed in the reporting quarter. b. . Line item records of Grievances and Appeals received in the quarter that includes: i. : The date received; ii. ; Identification as a Grievance or an Appeal; iii. ; Nature or general description of the reason for the Grievance or Appeal; iv. ; The disposition, as applicable; v. ; The date of the disposition, as applicable; vi. ; If a Subcontractor handles the Grievance or Appeal, the name of the Subcontractor responsible; and vii. and An indicator showing whether the Grievance or Appeal is for a Title XXI Enrollee or a Full-pay Plan Enrollee. c. . Line item records of Grievances and Appeals closed in the quarter that includes: i. : The date received; ii. ; Identification as a Grievance or an Appeal; iii. ; Nature or general description of the reason for the Grievance or Appeal; iv. ; The disposition; v. ; The date of the disposition; vi. ; If a Subcontractor handles the Grievance or Appeal, the name of the Subcontractor responsible; and vii. and An indicator showing whether the Grievance or Appeal is for a Title XXI Enrollee or a Full-pay Plan Enrollee. Insurer shall provide an annual summary analysis Grievance and Appeals report that includes: a. : Appeal response timeliness as a percentage of Appeals in the reporting Contract Year that were closed timely. Appeals closed in the Contract Year includes Appeals that were received in a different Contract Year for this Contract and closed in the reporting Contract Year. b. . Grievance response timeliness as a percentage of Grievances in the reporting Contract Year that were closed timely. Grievances closed in the Contract Year includes Grievances that were received in a different Contract Year for this Contract and closed in the reporting Contract Year. Summary of any Appeal trends. At a minimum Insurer shall consider whether any trends may be found regarding benefits appealed, Provider specialty types involved (as a function of the benefit, not related to Provider involvement in the Appeal process), and similarities in overturned Appeals. A description of activities Insurer has taken to address avoidable Appeals as well as any planned activities. Summary of any Grievance trends. At a minimum Insurer shall consider whether any trends may be found regarding Grievance topic and Providers involved (as a component of the Grievance, not related to Provider involvement in the Grievance process). A description of activities Insurer has taken to address avoidable Grievances as well as any planned activities. Insurer shall provide this information in the aggregate and broken out in the manner requested by FHKC. Insurer’s performance is subject to the performance guarantees established in Attachment C. Insurer shall provide Enrollees with reasonable assistance completing forms and taking other procedural steps related to Grievances and Appeals, upon request. Such assistance shall include providing auxiliary aids and services, interpretation services and toll-free numbers with TTY/TTD and interpreter capability. Insurer shall follow the requirements of 42 CFR 457.1207 and 42 CFR 438.10 and any method(s) established by FHKC when notifying Enrollees about any aspect of the Grievance and Appeal process. An Enrollee’s authorized representative, including Providers, may file Grievances and Appeals on the Enrollee’s behalf with the written consent of the Enrollee. Insurer shall not take punitive action against any Provider for filing an Appeal, requesting an expedited Appeal, or supporting an Enrollee’s request for an expedited Appeal.