Common use of Member Complaint and Appeal Process Clause in Contracts

Member Complaint and Appeal Process. The MCO must develop, implement and maintain a system for tracking, resolving, and reporting Member Complaints regarding its services, processes, procedures, and staff. The MCO must ensure that Member Complaints are resolved within 30 calendar days after receipt. The MCO is subject to remedies, including liquidated damages, if at least 98 percent of Member Complaints are not resolved within 30 days of the MCO’s receipt. Please see Attachment A, "Uniform Managed Care Contract Terms and Conditions," and Attachment B-3, “Deliverables/Liquidated Damages Matrix.” The MCO must develop, implement and maintain a system for tracking, resolving, and reporting Member Appeals regarding the denial or limited authorization of a requested service, including the type or level of service and the denial, in whole or in part, of payment for service. Within this process, the MCO must respond fully and completely to each Appeal and establish a tracking mechanism to document the status and final disposition of each Appeal. The MCO must ensure that Member Appeals are resolved within 30 calendar days, unless the MCO can document that the Member requested an extension or the MCO shows there is a need for additional information and the delay is in the Member's interest. The MCO is subject to liquidated damages if at least 98 percent of Member Appeals are not resolved within 30 days of the MCO’s receipt. Please see Attachment A, "Uniform Managed Care Contract Terms and Conditions," and Attachment B-3, “Deliverables/Liquidated Damages Matrix.” Medicaid MCOs must follow the Member Complaint and Appeal Process described in Section 8.2.7. CHIP MCOs must comply with the CHIP Complaint and Appeal Process described in Sections 8.4.3.

Member Complaint and Appeal Process. The MCO must develop, implement and maintain a system for tracking, resolving, and reporting Member Complaints regarding its services, processes, procedures, and staff. The MCO must ensure that Member Complaints are resolved within 30 calendar days after receipt. The MCO is subject to remedies, including liquidated damages, if at least 98 percent of Member Complaints are not resolved within 30 days of the MCO’s 's receipt. Please see Attachment A, "Uniform Managed Care Contract Terms and Conditions," and Attachment B-3, “"Deliverables/Liquidated Damages Matrix.” " The MCO must develop, implement and maintain a system for tracking, resolving, and reporting Member Appeals regarding the denial or limited authorization of a requested service, including the type or level of service and the denial, in whole or in part, of payment for service. Within this process, the MCO must respond fully and completely to each Appeal and establish a tracking mechanism to document the status and final disposition of each Appeal. The MCO must ensure that Member Appeals are resolved within 30 calendar days, unless the MCO can document that the Member requested an extension or the MCO shows there is a need for additional information and the delay is in the Member's interest. The MCO is subject to liquidated damages if at least 98 percent of Member Appeals are not resolved within 30 days of the MCO’s 's receipt. Please see Attachment A, "Uniform Managed Care Contract Terms and Conditions," and Attachment B-3, “"Deliverables/Liquidated Damages Matrix.” " Medicaid MCOs must follow the Member Complaint and Appeal Process described in Section 8.2.78.2.6. CHIP MCOs must comply with the CHIP Complaint and Appeal Process described in Sections 8.4.38.4.2.