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

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 that is not covered (see appeal). The term appeal, per 42 CFR 438.400, is defined as a request for a review of an action. An appeal is a special kind of complaint a member may make if they disagree with a decision to deny a request for health care services or payment for services they’ve already received. A member may also make a complaint if they disagree with a decision to stop services that they are receiving. For example, a member may ask for an appeal if Medicare doesn’t pay for an item or service they think they should be able to get. There is a specific process that a member’s health plan must use when they ask for an appeal. An adverse benefit determination, as defined in 42 CFR 438.400(b) is any of the following: ▪ 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; ▪ 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); or ▪ Denial of a member’s request to dispute a financial liability including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities. In accordance with 42 CFR 438.10(c), the Contractor must notify the requesting provider, and give the member written notice, of any decision considered an “adverse benefit determination” 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(b) and CFR 438.402(b)-(c), and must include: ▪ The adverse benefit determination the Contractor has taken or intends to take; ▪ The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge reasonable access to and copies of all documents, records, and other information relevant to the enrollee’s adverse benefit determination; ▪ The member’s or the provider’s right to request an appeal and the procedure for requesting such an appeal, including information on exhausting the Contractor’s one level of appeal; ▪ The procedure to request an external grievance procedure (External Review by Independent Review Organization) following exhaustion of the Contractor appeals process; ▪ 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 of these services.

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 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. 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 that is not covered (see appeal). The term appeal, per 42 CFR 438.400, appeal is defined as a request for a review of an action. An appeal is a special kind of complaint a member may make if they disagree with a decision to deny a request for health care services or payment for services they’ve already received. A member may also make a complaint if they disagree with a decision to stop services that they are receiving. For example, a member may ask for an appeal if Medicare doesn’t pay for an item or service they think they should be able to get. There is a specific process that a member’s health plan must use when they ask for an appeal. An adverse benefit determination, as defined in 42 CFR 438.400(b) is any of the following: ▪ • 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; ▪ 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); or ▪ Denial of a member’s request to dispute a financial liability including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities. In accordance with 42 CFR 438.10(c), the Contractor must notify the requesting provider, and give the member written notice, of any decision considered an “adverse benefit determination” 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(b) and CFR 438.402(b)-(c), and must include: ▪ The adverse benefit determination the Contractor has taken or intends to take; ▪ The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge reasonable access to and copies of all documents, records, and other information relevant to the enrollee’s adverse benefit determination; ▪ The member’s or the provider’s right to request an appeal and the procedure for requesting such an appeal, including information on exhausting the Contractor’s one level of appeal; ▪ The procedure to request an external grievance procedure (External Review by Independent Review Organization) following exhaustion of the Contractor appeals process; ▪ 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 of these services.;

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 systemsys tem, 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 that is not covered (see appeal). The term appeal, per 42 CFR 438.400, is defined as a request for a review of an action. An appeal is a special kind of complaint a member may make if they disagree with a decision to deny a request for health care services or payment for services they’ve already received. A member may also make a complaint if they disagree with a decision to stop services that they are receiving. For example, a member may ask for an appeal if Medicare doesn’t pay for an item or service they think they should be able to get. There is a specific spec ific process that a member’s health plan must use when they ask for an appeal. An adverse benefit determination, as defined in 42 CFR 438.400(b) is any of the following: ▪ 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; ▪ 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); or ▪ Denial of a member’s request to dispute a financial liability including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities. In accordance with 42 CFR 438.10(c), the Contractor must notify the requesting provider, and give the member written notice, of any decision considered an “adverse benefit determination” 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(b) and CFR 438.402(b)-(c), and must include: ▪ The adverse benefit determination the Contractor has taken or intends to take; ▪ The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge reasonable access to and copies of all documents, records, and other information relevant to the enrollee’s adverse benefit determination; ▪ The member’s or the provider’s right to request an appeal and the procedure for requesting such an appeal, including information on exhausting the Contractor’s one level of appeal; ▪ The procedure to request an external grievance procedure (External Review by Independent Review Organization) following exhaustion of the Contractor appeals process; ▪ 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 of these services.