Common use of Member Inquiries, Grievances & Appeals Clause in Contracts

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 CFR 438.404 and must include:  The action the Contractor has taken or intends to take;  The reasons for the action;  The member’s or the provider’s right to file an appeal;  The procedure to request a State fair hearing following exhaustion of the Contractor appeals process;  The circumstances under which expedited resolution is available and how to request it; and  The member’s right to have benefits continue pending resolution of the appeal, how to request continued benefits and the circumstances under which the member may be required to pay the costs.

Appears in 2 contracts

Samples: Contract #0000000000000000000018227, Contract #0000000000000000000018225

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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 serviceservice 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 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 CFR 438.404 and must include:  The action the Contractor has taken or intends to take;  The reasons for the action;  The member’s or the provider’s right to file an appeal;  The procedure to request a State fair hearing following exhaustion of the Contractor appeals process;  The circumstances under which expedited resolution is available and how to request it; and  The member’s right to have benefits continue pending resolution of the appeal, how to request continued benefits and the circumstances under which the member may be required to pay the costs.

Appears in 2 contracts

Samples: Contract, Contract

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 EXHIBIT 1.M SCOPE OF WORK 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;  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 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 CFR 438.404 and must include: The action the Contractor has taken or intends to take; The reasons for the action; The member’s or the provider’s right to file an appeal; The procedure to request a State fair hearing following exhaustion of the Contractor appeals process; The circumstances under which expedited resolution is available and how to request it; and The member’s right to have benefits continue pending resolution of the appeal, how to request continued benefits and the circumstances under which the member may be required to pay the costs.

Appears in 1 contract

Samples: Contract #0000000000000000000018225

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;  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;\ EXHIBIT 1. M SCOPE OF WORK • 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 CFR 438.404 and must include: The action the Contractor has taken or intends to take; The reasons for the action; The member’s or the provider’s right to file an appeal; The procedure to request a State fair hearing following exhaustion of the Contractor appeals process; The circumstances under which expedited resolution is available and how to request it; and The member’s right to have benefits continue pending resolution of the appeal, how to request continued benefits and the circumstances under which the member may be required to pay the costs.

Appears in 1 contract

Samples: Contract

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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- 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 CFR 438.404 and must include:  The action the Contractor has taken or intends to take;  The reasons for the action;  The member’s or the provider’s right to file an appeal;  The procedure to request a State fair hearing following exhaustion of the Contractor appeals process;  The circumstances under which expedited resolution is available and how to request it; and  The member’s right to have benefits continue pending resolution of the appeal, how to request continued benefits and the circumstances under which the member may be required to pay the costs.

Appears in 1 contract

Samples: Contract Amendment

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