Common use of Member Grievances and Appeals Clause in Contracts

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 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. 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 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.