Member Grievances and Appeals. The Contractor shall establish written policies and procedures governing the resolution of grievances and appeals. At a minimum, the grievance system shall include a grievance process, an appeal process, expedited review procedures, external review procedures and access to the State’s fair hearing system. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, shall comply with 42 CFR 438, Subpart F, which relates to the Contractor’s grievance system, as well as IC 27-13-10 and IC 27-13-10.1 (if the Contractor is licensed as an HMO) or IC 27-8-28 and IC 27-8-29 (if the Contractor is licensed as an accident and sickness insurer), as described within the Hoosier Healthwise MCE Policies and Procedures Manual. The term grievance, as defined in 42 CFR 43 8.400(b), is an expression of dissatisfaction about any matter other than an “action” as defined below. This may include dissatisfaction related to the quality of care of services rendered or available, aspects of interpersonal relationships such as rudeness of a provider or employee or the failure to respect the member’s rights. The term appeal is defined as a request for a review of an action. An action, as defined in 42 CFR 438.400(b), is the: Denial or limited authorization of a requested service, including the type or level of service; Reduction, suspension or termination of a previously authorized service; Denial, in whole or in part, of payment for a service; Failure to provide services in a timely manner, as defined by the State; Failure of a Contractor to act within the required timeframes; or For a resident of a rural area with only one Contractor, the denial of a member’s request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network (if applicable). The Contractor shall notify the requesting provider, and give the member written notice, of any decision considered an “action” taken by the Contractor, including, but not limited to any decision by the Contractor (i) to deny a service authorization request, (ii) to authorize a service in an amount, duration or scope that is less than requested, or (iii) that is adverse to the member regarding a medically frail designation. The notice shall meet the requirements of 42 CFR 438.404, “Notice of Action.” See Section 6.3.2, Authorization of Services and Notices of Action for additional information.
Member Grievances and Appeals. Member grievances, complaints, and/or appeals shall be resolved in accordance with Federal and/or State laws, regulations and Government Guidance and as set forth in CalOptima Policies relating to the applicable CalOptima Program. County agrees to cooperate in the investigation of the issues and be bound by CalOptima’s grievance decisions and, if applicable, State and/or Federal hearing decisions or any subsequent appeals.
Member Grievances and Appeals. The value of the reduced or terminated services as determined by the Department for the timeframe specified by the Department. AND $500 per Calendar Day for each day the PHP fails to provide continuation or restoration as required by the Department.
Member Grievances and Appeals. $500 per occurrence
Member Grievances and Appeals. $1,000 for each mediation or hearing that the PHP fails to attend as required
Member Grievances and Appeals. The Contractor shall establish written policies and procedures governing the resolution of grievances and appeals. At a minimum, the grievance system shall include a grievance process, an appeal process, expedited review procedures, external review procedures and access to the State’s fair hearing system. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, shall comply with 42 CFR 438, Subpart F, which relates to the Contractor’s grievance system, EXHIBIT 1.E HOOSIER HEALTHWISE SCOPE OF WORK as well as IC 27-13-10 and IC 27-13-10.1 (if the Contractor is licensed as an HMO) or IC 27-8-28 and IC 27-8-29 (if the Contractor is licensed as an accident and sickness insurer), as described within the Hoosier Healthwise MCE Policies and Procedures Manual. The term grievance, as defined in 42 CFR 43 8.400(b), is an expression of dissatisfaction about any matter other than an “action” as defined below. This may include dissatisfaction related to the quality of care of services rendered or available, aspects of interpersonal relationships such as rudeness of a provider or employee or the failure to respect the member’s rights. The term appeal is defined as a request for a review of an action. An action, as defined in 42 CFR 438.400(b), is the: Denial or limited authorization of a requested service, including the type or level of service; Reduction, suspension or termination of a previously authorized service; Denial, in whole or in part, of payment for a service excluding the denial of a claim that does not meet the definition of a clean claim. A “clean claim” is one in which all information required for processing the claim is present; Failure to provide services in a timely manner, as defined by the State; Failure of a Contractor to act within the required timeframes; or For a resident of a rural area with only one Contractor, the denial of a member’s request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network (if applicable). The Contractor shall notify the requesting provider, and give the member written notice, of any decision considered an “action” taken by the Contractor, including, but not limited to any decision by the Contractor (i) to deny a service authorization request, (ii) to authorize a service in an amount, duration or scope that is less than requested, or (iii) that is adverse to the member regarding a medically fr...
Member Grievances and Appeals. The Contractor shall establish written policies and procedures governing the resolution of grievances and appeals. At a minimum, the grievance system shall include a grievance process, an appeal process, expedited review procedures, external review procedures and access to the State’s fair hearing system. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, shall comply with 42 CFR 438, Subpart F, which relates to the Contractor’s grievance system, as well as IC 27-13-10 and IC 27-13-10.1 (if the Contractor is licensed as an HMO) or IC 27-8-28 and IC 27-8-29 (if the Contractor is licensed as an accident and sickness insurer), as described within the Hoosier Healthwise MCE Policies and Procedures Manual. The term grievance, as defined in 42 CFR 43 8.400(b), is an expression of dissatisfaction about any matter other than an “action” as defined below. This may include dissatisfaction related to the quality of care of services rendered or available, aspects of interpersonal relationships such as rudeness of a provider or employee or the failure to respect the member’s rights. The term appeal is defined as a request for a review of an action. An action, as defined in 42 CFR 438.400(b), is the: ▪ Denial or limited authorization of a requested service, including the type or level of service;
Member Grievances and Appeals. DVHA shall maintain its own internal grievance and appeals processes. Contractor, however, shall serve as the first line to intake grievances and appeals that are specific to actions taken by Contractor related to its Members. Contractor shall establish written policies and procedures, subject to review and approval by DVHA, governing the resolution of grievances and appeals. For any grievances not resolved by Contractor, Contractor shall offer the Member the opportunity to escalate the grievance to the DVHA grievances and appeals process. Contractor shall be responsible for addressing the following situations whenever a Member is attributed to the VMNG Program:
Member Grievances and Appeals. 1. ADHS Licensure Rules (A.A.C. R9-20-114) require that all licensed behavioral health service agencies have in place policies and procedures establishing a member complaint/grievance process. Additionally, ADHS has polices and procedures establishing a RBHA based Revised 11-01-01 APPENDIX A Effective 10-03-01 Page 8 of 18
Member Grievances and Appeals. The value of the reduced or terminated services as determined by Department for the timeframe specified by Department. AND $125 per Calendar Day for each day PIHP fails to provide continuation or restoration as required by Department.
