Common use of Member Complaint, Grievance, Appeal and State Fair Hearing Process Clause in Contracts

Member Complaint, Grievance, Appeal and State Fair Hearing 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 a State Fair Hearing by Members. The Complaint, Grievance, and Appeal policies and procedures shall be in accordance with 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 D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract. The Contractor shall not modify the Complaint, 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 submit a Complaint or 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 a State Fair Hearing with the Division of Medicaid, 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 a State Fair Hearing with the Division. The member may make written request for continuation of benefits within ten (10) calendar days of notice of Adverse Benefit Determination, pending the determination of a State Fair Hearing. Should a State Fair Hearing result in the reversal of an Adverse Benefit Determination made by the Contractor, the Contractor shall bear all costs associated with the hearing. These costs may include, but are not limited to, medical appropriateness reviews by the Division contracted Independent Physician Reviewers, hearing officer’s fees, attorney’s fees, and court reporter’s fees. 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 5 below and Exhibit D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract outline additional specific requirements pertaining to Complaints, Grievances, and Appeals.

Member Complaint, Grievance, Appeal and State Fair Hearing 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 a State Fair Hearing by Members. The Complaint, Grievance, Grievance and Appeal policies and procedures shall be in accordance with 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 D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract. The Contractor shall not modify the Complaint, Grievance, 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, 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 submit a Complaint or 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 a State Fair Hearing with the Division of Medicaid, upon notification of a Contractor Adverse Benefit Determination, subsequent to an Appeal of the Contractor Adverse Benefit Determination. The Member must exhaust all Contractor CCO level Appeal procedures prior to requesting a State Fair Hearing with the Division. The member may make written request for continuation of benefits within ten (10) calendar days of notice of Adverse Benefit Determination, pending the determination of a State Fair Hearing. Should a State Fair Hearing result in the reversal of an Adverse Benefit Determination made by the ContractorCCO, the Contractor CCO shall bear all costs associated with the hearing. These costs may include, but are not limited to, medical appropriateness reviews by the Division contracted Independent Physician Reviewers, hearing officer’s fees, attorney’s fees, and court reporter’s fees. 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 5 below and Exhibit D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract outline additional specific requirements pertaining to Complaints, Grievances, and Appeals.

Member Complaint, Grievance, Appeal and State Fair Hearing 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 a State Fair Hearing by Members. The Complaint, Grievance, and Appeal policies and procedures shall be in accordance with 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 D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract. The Contractor shall not modify the Complaint, 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 submit a Complaint or 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 a State Fair Hearing with the Division of Medicaid, 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 a State Fair Hearing with the Division. The member may make written request for continuation of benefits within ten (10) calendar days of notice of Adverse Benefit Determination, pending the determination of a State Fair Hearing. Should a State Fair Hearing result in the reversal of an Adverse Benefit Determination made by the Contractor, the Contractor shall bear all costs associated with the hearing. These costs may include, but are not limited to, medical appropriateness reviews by the Division contracted Independent Physician Reviewers, hearing officer’s fees, attorney’s fees, and court reporter’s fees. 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 5 below and Exhibit D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract outline additional specific requirements pertaining to Complaints, Grievances, and Appeals.

Member Complaint, Grievance, Appeal and State Fair Hearing 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 a State Fair Hearing by Members. The Complaint, Grievance, Grievance and Appeal policies and procedures shall be in accordance with 42 C.F.R. Part 438, Subpart F and the State’s Quality Strategy, with the modifications that are incorporated in the Contract contract and Exhibit D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract. The Contractor shall not modify the Complaint, Grievance, 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, 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 submit a Complaint or 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 a State Fair Hearing with the Division of Medicaid, upon notification of a Contractor Adverse Benefit DeterminationAction, subsequent to an Appeal of the Contractor Adverse Benefit DeterminationAction. The Member must exhaust all Contractor CCO level Grievance and Appeal procedures prior to requesting a State Fair Hearing with the Division. The member may make written request for continuation of benefits within ten (10) calendar days of notice of Adverse Benefit Determination, pending the determination of a State Fair Hearing. Should a State Fair Hearing result in the reversal of an Adverse Benefit Determination made by the Contractor, the Contractor shall bear all costs associated with the hearing. These costs may include, but are not limited to, medical appropriateness reviews by the Division contracted Independent Physician Reviewers, hearing officer’s fees, attorney’s fees, and court reporter’s fees. 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 FederalFederal regulations. Table 5 below and Exhibit D, Member Complaint, Grievance, Appeal, and State Fair Hearing Process, of this Contract outline additional specific requirements pertaining to Complaints, Grievances, and Appeals.