Medicaid Advantage Action and Grievance System Additional Provisions Sample Clauses

Medicaid Advantage Action and Grievance System Additional Provisions. 14.4 Notification of Medicaid Advantage Action and Grievance System Procedures 14.5 Complaint, Complaint Appeal and Action Appeal Investigation Determinations Section 15 Access Requirements Section 16 Quality Management and Performance Improvement Section 17 Monitoring and Evaluation 17.1 Right To Monitor Contractor Performance 17.2 Cooperation During Monitoring And Evaluation 17.3 Cooperation During On-Site Reviews

Medicaid Advantage Action and Grievance System Additional Provisions a) The Contractor must have in place effective mechanisms to ensure consistent application of review criteria for Service Authorization Determinations and consult with the requesting provider when appropriate. b) If the Contractor subcontracts for Service Authorization Determinations and utilization review, the Contractor must ensure that its subcontractors have in place and follow written policies and procedures for delegated activities regarding processing requests for initial and continuing authorization of services consistent with Article 49 of the PHL, 10 NYCRR Part 98, 42 CFR Part 438, Appendix F of this Agreement, and the Contractor's policies and procedures. c) The Contractor must ensure that compensation to individuals or entities that perform Service Authorization Determination and utilization management activities is not structured to include incentives that would result in the denial, limiting, or discontinuance of Medically Necessary services to Enrollees. d) The Contractor or its subcontractors may not arbitrarily deny or reduce the amount, duration, or scope of a covered service solely because of the diagnosis, type of illness, or Enrollee's condition. The Contractor may place appropriate limits on a service on the basis of criteria such as Medical Necessity or utilization control, provided that the services furnished can reasonably be expected to achieve their purpose. e) The Contractor shall ensure that its Medicaid Advantage Grievance System includes methods for prompt internal adjudication of Enrollee Complaints, Complaint Appeals and Action Appeals and provides for the maintenance of a written record of all Complaints, Complaint Appeals and Action Appeals received and reviewed and their disposition, as specified in Appendix F of this Agreement. f) The Contractor shall ensure that persons with authority to require corrective action participate in the Medicaid Advantage Grievance System.