Common use of MCO Requirements Clause in Contracts

MCO Requirements. The MCO must establish internal grievance and appeal procedures (informal and formal steps) that permit an eligible enrollee, or a provider on behalf of an enrollee, to challenge the denials of coverage of medical assistance or denials of payment for medical assistance: a. The MCO must establish and maintain a grievance and appeal procedure, which has been approved by the State, to provide adequate and reasonable procedures for the expeditious resolution of grievances initiated by enrollees or their providers concerning any matter relating to any provision of the MCO’s health maintenance contracts, including, but not limited to, claims regarding the scope of coverage for health care services; denials, reductions, cancellations or nonrenewals of enrollee coverage; failure to provide services in a timely manner, observance of an enrollee’s rights as a patient; and the quality of the health care services rendered. b. A detailed description of the MCO’s enrollee grievance and appeal procedure must be included in the member handbook provided to enrollees. This procedure must be administered at no cost to the enrollee. c. As part of MCO’s enrollee grievance and appeal procedure, the MCO must: i. Make available both informal and formal steps to resolve the grievance; ii. Designate at least one grievance coordinator; iii. Permit that both grievances and appeals can be filed orally or in writing; iv. Provide reasonable assistance in completing the procedure, including but not limited to completing forms and toll-free phone numbers as specified by the MCO; v. Acknowledge receipt of grievances and appeals; vi. Involve some person with problem solving authority at each level of the grievance procedure; vii. Ensure that individuals reviewing and making decisions on grievances and appeals were not previously involved in decisions related to the grievance or appeal under review; viii. Ensure that individuals reviewing medically related grievances or denials of expedited resolution of an appeal have appropriate clinical expertise, as determined by the State in treating the enrollee’s condition or disease; ix. Process and provide notice to affected parties regarding the enrollee grievance in a reasonable length of time not to exceed 45 days from the day the MCO receives the grievance, unless the enrollee requests an extension or the MCO shows that a delay is necessary and in the interest of the enrollee; x. Ensure that standard resolution and notice occurs with the timeframes established by BMS and that such timeframes may be extended up to 14 days upon the request of the enrollee or if the MCO shows that additional information is necessary and that the delay is in the interest of the enrollee; and xi. Ensure that if the timeframe for resolving a grievance is extended for any reason other than an enrollee request, the MCO must give the enrollee written notice of the reason for the delay.

MCO Requirements. The MCO must establish internal grievance and appeal procedures (informal and formal steps) that permit an eligible enrollee, or a provider on behalf of an enrollee, to challenge the denials of coverage of medical assistance or denials of payment for medical assistance: a. The MCO must establish and maintain a grievance and appeal procedure, which has been approved by the State, to provide adequate and reasonable procedures for the expeditious resolution of grievances initiated by enrollees or their providers concerning any matter relating to any provision of the MCO’s health maintenance contracts, including, but not limited to, claims regarding the scope of coverage for health care services; denials, reductions, cancellations or nonrenewals of enrollee coverage; failure to provide services in a timely manner, observance of an enrollee’s rights as a patient; and the quality of the health care services rendered. b. A detailed description of the MCO’s enrollee grievance and appeal procedure must be included in the member handbook provided to enrollees. This procedure must be administered at no cost to the enrollee. c. As part of MCO’s enrollee grievance and appeal procedure, the MCO must: i. Make available both informal and formal steps to resolve the grievance; ii. Designate at least one grievance coordinator; iii. Permit that both grievances and appeals can be filed orally or in writing; iv. Provide reasonable assistance in completing the procedure, including but not limited to completing forms forms, auxiliary aids and services, and toll-free phone numbers with adequate TYY/TDD and interpreter capability as specified by the MCO; v. Acknowledge receipt of grievances and appeals; vi. Involve some person with problem solving authority at each level of the grievance procedure; vii. Ensure that individuals reviewing and making decisions on grievances and appeals were not previously involved in decisions related to the grievance or appeal under review; viii. Ensure that individuals reviewing and making decisions on grievances and appeals take into account all comments, documents, records, and other information submitted by the enrollee or their representative without regard to whether the information was submitted or considered in the initial adverse benefit determination; ix. Ensure that individuals reviewing medically related grievances or denials of expedited resolution of an appeal have appropriate clinical expertise, as determined by the State in treating the enrollee’s condition or disease; ix. x. Process and provide notice to affected parties regarding the enrollee grievance in a reasonable length of time not to exceed 45 thirty (30) days from the day the MCO receives the grievance, unless the enrollee requests an extension or the MCO shows that a delay is necessary and in the interest of the enrollee; x. xi. Ensure that standard resolution and notice for a grievance occurs with the timeframes established by BMS and that such timeframes may be extended up to 14 fourteen (14) days upon the request of the enrollee or if the MCO shows that additional information is necessary and that the delay is in the interest of the enrollee; and xixii. Ensure that if the timeframe for resolving a grievance is extended for any reason other than an enrollee request, the MCO must give the enrollee written notice of the reason for the delaydelay and inform the enrollee of the right to file a grievance if he or she disagrees with the decision.

MCO Requirements. The MCO must establish internal grievance and appeal procedures (informal and formal steps) that permit an eligible enrollee, or a provider on behalf of an enrollee, to challenge the denials of coverage of medical assistance or denials of payment for medical assistance: a. The MCO must shall establish and maintain a grievance and appeal procedure, which has been approved by the State, to provide adequate and reasonable procedures for the expeditious resolution of grievances initiated by enrollees or their providers concerning any matter relating to any provision of the MCO’s health maintenance contracts, including, but not limited to, claims regarding the scope of coverage for health care services; denials, reductions, cancellations or nonrenewals of enrollee coverage; failure to provide services in a timely manner, observance of an enrollee’s rights as a patient; and the quality of the health care services rendered. b. A detailed description of the MCO’s enrollee grievance and appeal procedure must shall be included in the member handbook provided to enrollees. This procedure must shall be administered at no cost to the enrollee. c. As part of MCO’s enrollee grievance and appeal procedure, the MCO mustshall: i. Make available both informal and formal steps to resolve the grievance; ii. Designate at least one grievance coordinator; iii. Permit that both grievances and appeals can be filed orally or in writing; iv. Provide reasonable assistance in completing the procedure, including but not limited to completing forms and toll-free phone numbers as specified by the MCO; v. Acknowledge receipt of grievances and appeals; vi. Involve some person with problem solving authority at each level of the grievance procedure; vii. Ensure that individuals reviewing and making decisions on grievances and appeals were not previously involved in decisions related to the grievance or appeal under review; viii. Ensure that individuals reviewing medically related grievances or denials of expedited resolution of an appeal have appropriate clinical expertise, as determined by the State in treating the enrollee’s condition or disease; ix. Process and provide notice to affected parties regarding the enrollee grievance in a reasonable length of time not to exceed 45 days from the day the MCO receives the grievance, unless the enrollee requests an extension or the MCO shows that a delay is necessary and in the interest of the enrollee; x. Ensure that standard resolution and notice occurs with the timeframes established by BMS and that such timeframes may be extended up to 14 days upon the request of the enrollee or if the MCO shows that additional information is necessary and that the delay is in the interest of the enrollee; and xi. Ensure that if the timeframe for resolving a grievance is extended for any reason other than an enrollee request, the MCO must shall give the enrollee written notice of the reason for the delay.