Member Complaint, Grievance, Appeal and Independent External Review Process. The Contractor shall draft and disseminate to Members, Providers, and Subcontractors, a system and procedure, which has the prior written approval of the Division for the receipt and adjudication of Complaints, Grievances, and Appeals or requests for an Independent External Review by Members. The Complaint, Grievance and Appeal policies and procedures shall be in accordance with 42 C.F.R. §457.1260 et. seq., 42 C.F.R. Part 438, Subpart F and the State’s Quality Strategy, with the modifications that are incorporated in the Contract and Exhibit E, Member Complaint, Grievance, Appeal, and Independent External Review Process, of this Contract, except for the Continuation of Benefits provision found in §438.420. The Contractor shall not modify the Grievance and Appeal procedure without the prior approval of the Division, and shall provide the Division with a copy of the modification. The Contractor shall review the Complaint, Grievance and Appeal procedure at reasonable intervals, but no less than annually, for amending as needed, with the prior written approval of the Division, in order to improve said system and procedure. The Division shall have the right to intercede on a Member’s behalf at any time during the Contractor’s Complaint, Grievance, and/or Appeal process whenever there is an indication from the Member, or, where applicable, authorized person, that a serious quality of care issue is not being addressed timely or appropriately. Additionally, the Member may be accompanied by a representative of the Member’s choice to any proceedings. The Contractor shall provide Members as a part of the Member handbook, information on how they or their representative(s) can file a Grievance or an Appeal, and the resolution process. The Member information shall also advise Members of their right to file a request for an Independent External Review following the outcome of the Appeal to Contractor, upon notification of a Contractor Adverse Benefit Determination, subsequent to an Appeal of the Contractor Adverse Benefit Determination. The Member must exhaust all Contractor level Appeal procedures prior to requesting an Independent External Review. The Contractor shall use the definitions for Complaints, Grievances, and Appeals as set forth in this section and adhere to time frames required by this Contract and Federal. Table 3 below and Exhibit E, Member Complaint, Grievance, Appeal, and Independent External Review Process, of this Contract outline additional specific requirements pertaining to Complaints, Grievances, and Appeals.
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Member Complaint, Grievance, Appeal and Independent External Review Process. The Contractor shall draft and disseminate to Members, Providers, and Subcontractors, a system and procedure, which has the prior written approval of the Division for the receipt and adjudication of Complaints, Grievances, and Appeals or requests for an Independent External Review by Members. The Complaint, Grievance and Appeal policies and procedures shall be in accordance with 42 C.F.R. §457.1260 et. seq., 42 C.F.R. Part 438, Subpart F and the State’s Quality Strategy, with the modifications that are incorporated in the Contract and Exhibit E, Member Complaint, Grievance, Appeal, and Independent External Review Process, of this Contract, except for the Continuation of Benefits provision found in §438.420. The Contractor shall not modify the Grievance and Appeal procedure without the prior approval of the Division, and shall provide the Division with a copy of the modification. The Contractor shall review the Complaint, Grievance and Appeal procedure at reasonable intervals, but no less than annually, for amending as needed, with the prior written approval of the Division, in order to improve said system and procedure. The Division shall have the right to intercede on a Member’s behalf at any time during the Contractor’s Complaint, Grievance, and/or Appeal process whenever there is an indication from the Member, or, where applicable, authorized person, that a serious quality of care issue is not being addressed timely or appropriately. Additionally, the Member may be accompanied by a representative of the Member’s choice to any proceedings. The Contractor shall provide Members as a part of the Member handbook, information on how they or their representative(s) can file a Grievance or an Appeal, and the resolution process. The Member information shall also advise Members of their right to file a request for an Independent External Review following the outcome of the Appeal to Contractor, upon notification of a Contractor Adverse Benefit Determination, subsequent to an Appeal of the Contractor Adverse Benefit Determination. The Member must exhaust all Contractor level Appeal procedures prior to requesting an Independent External Review. The Contractor shall use the definitions for Complaints, Grievances, and Appeals as set forth in this section and adhere to time frames required by this Contract and Federal. Table 3 below and Exhibit E, Member Complaint, Grievance, Appeal, and Independent External Review Process, of this Contract outline additional specific requirements pertaining to Complaints, Grievances, and Appeals.
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