Member Appeals and Grievances. PacifiCare shall be responsible for resolving Member claims for benefits under the Managed Care Plans and all other claims against PacifiCare. PacifiCare shall resolve such claims utilizing the Member Appeals and Grievance Procedures set forth in the Subscriber Agreement and the Provider Manual. Medical Group shall assist PacifiCare in the handling of Member complaints, grievances and appeals, consistent with the Member Appeals and Grievance Procedures. In the event an oral or written complaint, grievance or appeal is presented to Medical Group or any of its Participating Providers relating to benefits or coverage under a Managed Care Plan, Medical Group or its Participating Providers will immediately refer Members to contact PacifiCare or deliver any written complaint, grievance or appeal to PacifiCare for handling pursuant to the Member Appeals and Grievance Procedures. Medical Group and its Participating Providers shall comply with all final determinations made by PacifiCare through the Member Appeals and Grievance Procedures. Member claims against Medical Group or its Participating Providers, other than claims for benefits under the Managed Care Plans, are not subject to the Member Appeals and Grievance Procedures and are not governed by this Agreement.
Member Appeals and Grievances. The Contract must address the provider's obligation to cooperate with the Member in regard to Member appeals and grievance procedures.
Member Appeals and Grievances. PacifiCare shall be responsible for resolving Member claims for benefits under the Managed Care Plans and all other claims against PacifiCare. PacifiCare shall resolve such claims utilizing the Member Appeals and Grievance Procedures set forth in the Subscriber Agreement and the Provider Manual. Medical Group shall assist PacifiCare in the handling of Member complaints, grievances and appeals, consistent with the Member Appeals and Grievance Procedures. In the event an oral or written complaint, grievance or appeal is presented to Medical Group or any of its Participating Providers relating to benefits or coverage under a Managed Care Plan, Medical Group or its Participating Providers will immediately refer Members to contact PacifiCare or deliver any written complaint, grievance or appeal to PacifiCare for handling pursuant to the Member Appeals and Grievance Procedures. Medical Group and its Participating Providers shall comply with all final determinations made by PacifiCare through the Member Appeals and Grievance Procedures as they relate to Medical Group Services. PacifiCare agrees that it shall utilize Medical Group’s Participating Providers when available to provide any care related to a determination, unless otherwise directed by a government agency. Member claims against Medical Group or its Participating Providers, other than claims for benefits under the Managed Care Plans, are not subject to the Member Appeals and Grievance Procedures and are not governed by this Agreement.
17. Section 7.5, Disputes Between PacifiCare and Medical Group, is hereby amended in its entirety as follows
Member Appeals and Grievances. Health Plan shall be responsible for resolving Member claims for benefits under the Managed Care Plans and all other claims against Health Plan. Health Plan shall resolve such claims utilizing the Member Appeals and Grievance Procedures set forth in the Subscriber Agreement and the Provider Manual. Medical Group shall assist Health Plan in the handling of Member complaints, grievances and appeals, consistent with the Member Appeals and Grievance Procedures. In the event an oral or written complaint, grievance or appeal is presented to Medical Group or any of its Participating Providers relating to benefits or coverage under a Managed Care Plan and is not resolved within two (2) calendar days, Medical Group or its Participating Provider will immediately deliver such complaint, grievance or appeal to Health Plan for handling pursuant to the Member Appeals and Grievance Procedures. At the end of each month, Medical Group shall submit a report to Health Plan of all Member complaints and grievances which were received and resolved by Medical Group and its Participating Providers within two (2) calendar days during the previous month. The monthly report shall include the Member's name and Health Plan identification number, date of complaint, nature of complaint, and the resolution of complaint. Medical Group and its Participating Providers shall comply with all final determinations made by Health Plan through the Member Appeals and Grievance Procedures. Member claims against Medical Group or its Participating Providers, other than claims for benefits under the Managed Care Plans, are not subject to the Member Appeals and Grievance Procedures and are not governed by this Agreement.
Member Appeals and Grievances. The third party provider must recognize that members have the right to file appeals or grievances and assure that such action will not adversely affect the way that the third party provider treats the member. The third party provider agrees to cooperate and not interfere with the members’ appeals, grievances and fair hearings procedures and investigations and timeframes in accordance with Article X, Grievances and Appeals. The Indian Health Care Provider (IHCP) must furnish the following grievance, appeal and fair hearing procedures and timeframes to all providers and subcontractors at the time that they enter into a contract:
a. The member’s right to a fair hearing, how to obtain a hearing, and representation rules at a hearing;
b. The member’s right to file grievances and appeals and their requirements and timeframes for filing;
c. The availability of assistance in filing;
d. The toll-free numbers to file oral grievances and appeals;
e. The member’s right to request continuation of benefits during an appeal or fair hearing filing and, if the Indian Health Care Provider (IHCP)’s action is upheld in a hearing, the member may be liable for the cost of any continued benefits; and
f. The member’s appeal rights to challenge the failure of the Indian Health Care Provider (IHCP) to cover a service.
Member Appeals and Grievances. Fitness Center shall cooperate and comply with all ASH Clients, and CMS requirements regarding appeals of members, including the obligation to provide information to ASH Fitness within the timeframe reasonably requested for such purpose. [42 C.F.R. 422.562(a)]
Member Appeals and Grievances. The third party provider must recognize that members have the right to file appeals or grievances and assure that such action will not adversely affect the way that the third party provider treats the member. The third party provider agrees to cooperate and not interfere with the members’ appeals, grievances and fair hearings procedures and investigations and timeframes in accordance with Article X, Grievances and Appeals. The IHCP must furnish the following grievance, appeal and fair hearing procedures and timeframes to all providers and subcontractors at the time that they enter into a contract: The member’s right to a fair hearing, how to obtain a hearing, and representation rules at a hearing; The member’s right to file grievances and appeals and their requirements and timeframes for filing; The availability of assistance in filing; The toll-free numbers to file oral grievances and appeals; The member’s right to request continuation of benefits during an appeal or fair hearing filing and, if the IHCP's action is upheld in a hearing, the member may be liable for the cost of any continued benefits; and The member’s appeal rights to challenge the failure of the IHCP to cover a service.
Member Appeals and Grievances. Provider shall cooperate with Covered Persons in regard to Covered Person appeals and grievance procedures. (Attachment F.a.xii. p.319) Provider Network. Partners shall require network providers of services provided under Outpatient Commitment to a member to notify the Partners of the Outpatient Commitment order upon receipt. (Attachment F.a.xiii.p.319) Provider Network. Providers must ensure that Lesbian, Gay, Bisexual, Transgender, or Questioning (LGBTQ) members who obtain covered services are not subject to treatment or bias that does not affirm their orientation. (Attachment F.a.xiv.p.319)
Member Appeals and Grievances. The subcontractor must recognize that members have the right to file appeals or grievances and assure that such action will not adversely affect the way that the subcontractor treats the member. The subcontractor agrees to cooperate and not interfere with the members’ appeals, grievances and fair hearings procedures and investigations and timeframes in accordance with Article XI, Grievances and Appeals, page 161. The MCO must furnish the following grievance, appeal and fair hearing procedures and timeframes to all providers and subcontractors at the time that they enter into a contract:
a. The member’s right to a fair hearing, how to obtain a hearing, and representation rules at a hearing;
b. The member’s right to file grievances and appeals and their requirements and timeframes for filing;
c. The availability of assistance in filing;
d. The toll-free numbers to file oral grievances and appeals;
e. The member’s right to request continuation of benefits during an appeal or fair hearing filing and, if the MCO’s action is upheld in a hearing, the member may be liable for the cost of any continued benefits; and
f. The member’s appeal rights to challenge the failure of the MCO to cover a service.
Member Appeals and Grievances
