MCO-Requested Disenrollment Procedure. a) The MCO shall complete and submit to the Department contract coordinator form F-02403 requesting the member’s disenrollment along with documentation of the basis for the request, a thorough review of issues leading to the request and evidence that supports the request. For disenrollment requests based on a member no longer accepting services authorized by the MCO, this documentation must include the last date on which services were provided to the member, a copy of the certified letter sent to the member and relevant case notes.
Appears in 7 contracts
Samples: www.dhs.wisconsin.gov, www.dhs.wisconsin.gov, dhs.wisconsin.gov
MCO-Requested Disenrollment Procedure. a) The MCO shall complete and submit to the Department contract coordinator form F-02403 F-00221B requesting the member’s disenrollment along with documentation of the basis for the request, a thorough review of issues leading to the request and evidence that supports the request. For disenrollment requests based on a member no longer accepting services authorized by the MCO, this documentation must include the last date on which services were provided to the member, a copy of the certified letter sent to the member and relevant case notes.
Appears in 7 contracts
Samples: dhs.wisconsin.gov, clpc.ucsf.edu, www.dhs.wisconsin.gov
MCO-Requested Disenrollment Procedure. a) The MCO shall complete and submit to the Department contract coordinator form F-02403 requesting a written request to process the member’s disenrollment along with disenrollment, which includes documentation of the basis for the request, a thorough review of issues leading to the request and evidence that supports the request. For disenrollment requests based on a member no longer accepting services authorized by the MCO, this documentation must include the last date on which services were provided to the member, a copy of the certified letter sent to the member and relevant case notes.
Appears in 4 contracts
Samples: Partnership Contract, oldsite.justiceinaging.org, nsclcarchives.org
MCO-Requested Disenrollment Procedure. a) The MCO shall complete and submit to the Department contract coordinator form F-02403 requesting a written request to process the member’s disenrollment along with disenrollment, which includes documentation of the basis for the request, a thorough review of issues leading to the request and evidence that supports the request. For disenrollment requests based on a member no longer accepting services authorized by the MCO, this documentation must include the last date on which services were provided to the member, a copy of the certified letter sent to the member and relevant case notes.
Appears in 1 contract
Samples: clpc.ucsf.edu