Member Inquiries, Grievances & Appeals. The Contractor shall establish written policies and procedures governing the resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, an appeals process, expedited review procedures and access to the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416. The State will review this information as part of the State’s quality strategy. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, must comply with law, including 42 CFR 438, Subpart F as well as IC 27-13-10 and IC 27-13-
Member Inquiries, Grievances & Appeals. In compliance with CFR 438.402(c)(1) and 42 CFR 438.408, the Contractor shall allow members to file appeals, grievances, and State fair hearing requests (after receiving notice that an adverse benefit determination is upheld). The Contractor shall allow providers, or authorized representatives, acting on behalf of the member and with the member’s written consent, to request an appeal, file a grievance, or request a State fair hearing request per 42 CFR 438.402(c)(1) and 42 CFR 438.408. The Contractor cannot require providers and/or members to use a specific form to submit an appeal. The Contractor shall have a grievance and appeals system in place in accordance with 42 CFR 438.402(a) and 42 CFR 438.228(a) and establish written policies and procedures governing the process and resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, a single-level appeals process, expedited review procedures and access to external grievance procedure as well as the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416. The State will review this information as part of the State’s quality strategy. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, must comply with law, including 42 CFR 438, Subpart F 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). The term inquiry refers to a concern, issue or question that is expressed orally by a member that will be resolved by the close of the next business day. The term grievance, as defined in 42 CFR 438.400(b), is an expression of dissatisfaction about any matter other than an “adverse benefit determination” 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. A grievance is a complaint about the way a member’s health plan is giving care. For example, a member may file a grievance if the member has a problem calling the plan or if the member is unhappy with the way a staff person at the plan has behaved toward them. A grievance is not the way to deal with a complaint about a treatment decision or a service...
Member Inquiries, Grievances & Appeals. The Contractor shall establish written policies and procedures governing the resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, an appeals process, expedited review procedures and access to external grievance procedure as well as the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416.
Member Inquiries, Grievances & Appeals. The Contractor shall establish written policies and procedures governing the resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, an appeals process, expedited review procedures and access to the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416. The State will review this information as part of the State’s quality strategy. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, must comply with law, including 42 CFR 438, Subpart F 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). The term inquiry refers to a concern, issue or question that is expressed orally by a member that will be resolved by the close of the next business day. 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 must notify the requesting provider, and give the member written notice, of any decision considered an “action” taken by the Contractor, including any decision by the Contractor to deny a service authorization request (a request for the provision of a service by or on behalf of a member), or to authorize a service in an amount, duration or scope that is less than requested. The notice must meet the requirements of 42 ...
