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 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 frail designation. The notice shall meet the re...
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. $1,000 for each mediation or hearing that the PHP fails to attend as required
Member Grievances and Appeals. $500 per occurrence
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.
12. Failure to attend mediations and hearings as scheduled as specified in Section V.B.6.
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:
a. A Member expresses dissatisfaction (a grievance) with the VMNG Program, a VMNG Program policy or a provider affiliated with the VMNG Program; or
b. A Member wishes to appeal a decision or action taken by the VMNG Program (in accordance with the definitions provided in 42 CFR § 438.400(b)).
4.11.1 State Fair Hearing Process In accordance with 42 CFR § 438.408, the State of Vermont maintains a fair hearing process which allows Members the opportunity to appeal Contractor’s decisions to the State of Vermont. If there is a reduction or termination in covered services in amount, duration or scope, then Members must have access to grievances, appeals and a state fair hearing process. In situations where an Attributed Member has exhausted Contractor’s grievance and appeals process and is still dissatisfied, the Member may request a DVHA fair hearing within ninety (90) days from the date of Contractor’s decision. Although DVHA staff will coordinate the fair hearing process, Contractor shall be responsible for providing all requested information made by DVHA related to the Member appeal in the timeframe requested by the State of Vermont. Contractor shall assist DVHA, as needed and requested by DVHA, in support of the fair hearing process including, but not limited to, attending the fair hearing. Contractor shall include the DVHA fair hearing process as part of the written internal process for resolution of appeals.
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 grievance and appeals process for persons with serious mental illness and appeals process for all other member populations, with the exception of prevention participants. All of these processes may culminate in administrative fair hearings and possible judicial review.
2. Contractors shall assist eligible and enrolled persons in understanding their right to file grievances (SMI) and appeals. Contractors are required to advise Members of both the agency and the RBHA grievance and appeals processes at the time services are initiated. Additionally, the Contractor must provide written notice to Members of their right to appeal decisions to deny, reduce, suspend or terminate services when required to do so by AHCCCS, ADHS and RBHA policies and procedures.
3. The Contractor may attempt to resolve member complaints and disputes through their internal agency complaint process, however, the Contractor must advise Members that they may use the RBHA grievance and appeals process instead of the Contractor's and may not interfere with a Member's right to file a grievance or appeal with the RBHA. Final Sep 30-02 Effective 7-01-02 Page 58 -------------------------------------------------------------------------------- [LOGO] Community Partnership SUBCONTRACT AGREEMENT of Southern Arizona COMPREHENSIVE SERVICE NETWORK Regional Behavioral The Providence Service Corporation Health Authority AMENDMENT #6 ------------------------------------------- CONTRACT NUMBER: A0108 FY 02/03 --------------------------------------------------------------------------------
4. The Contractor must have in place policies and procedures that are in substantial compliance with the RBHA's policies and procedures and that require the Contractor's staff to participate effectively in the RBHA, ADHS and AHCCCS grievance and appeals processes.
5. The Contractor shall ensure that any services in an AHCCCS Director's decision are promptly provided, irrespective of whether nor not a petition for rehearing is filed.
Member Grievances and Appeals. The County PIHP is required to implement and enforce all of the requirements regarding member grievance and appeals processes, including Title 42 Code of Federal Regulations Part 438 Subpart F, as contained in the Member Grievances and Appeals Guide, dated December 2021, which is fully incorporated herein by reference.
Member Grievances and Appeals. The County is required to implement and enforce all of the requirements regarding member grievance and appeals processes, including Title 42 Code of Federal Regulations Part 438 Subpart F, as contained in the Member Grievances and Appeals Guide, Dated January 1, 2020, which is fully incorporated herein by reference.
