Common use of Member Notice of Grievance, Appeal and Fair Hearing Clause in Contracts

Member Notice of Grievance, Appeal and Fair Hearing. Procedures The Contractor shall provide specific information regarding member grievance, appeal and State fair hearing procedures and timeframes to members, as well as providers and subcontractors at the time they enter a contract with the Contractor. This information shall be included in the Member Handbook as described in Section 4.4.1. The information provided shall be approved by OMPP in accordance with Section 4.5, and, as required under 42 CFR 438.10(g)(1), include the following:  The right to file grievances and appeals;  The requirements and timeframes for filing a grievance or appeal;  The availability of assistance in the filing process;  The toll-free numbers that the member can use to file a grievance or appeal by phone;  The fact that, if requested by the member and under certain circumstances: 1) benefits will continue if the member files an appeal or requests a FSSA fair hearing within the specified timeframes; and 2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member; The right to request an External Review by an Independent Review Organization of decisions listed in 4.9.4; and  For a FSSA fair hearing:  The right to a hearing;  The method for obtaining a hearing; and  The rules that govern representation at the hearing.

Member Notice of Grievance, Appeal and Fair Hearing. Procedures The Contractor shall provide specific information regarding member grievance, appeal and State fair hearing procedures and timeframes to members, as well as providers and subcontractors at the time they enter a contract with the Contractor. This information shall be included in the Member Handbook as described in Section 4.4.1. The information provided shall be approved by OMPP in accordance with Section 4.5, and, as required under 42 CFR 438.10(g)(1), include the following:  The right to file grievances and appeals;  The requirements and timeframes for filing a grievance or appeal;  The availability of assistance in the filing process;  The toll-free numbers that the member can use to file a grievance or appeal by phone;  The fact that, if requested by the member and under certain circumstances: 1) benefits will continue if the member files an appeal or requests a FSSA fair hearing within the specified timeframes; and 2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member; The right to request an External Review by an Independent Review Organization of decisions listed in 4.9.4; and  For a FSSA fair hearing: EXHIBIT 1.E HOOSIER HEALTHWISE SCOPE OF WORK  The right to a hearing;  The method for obtaining a hearing; and  The rules that govern representation at the hearing.

Member Notice of Grievance, Appeal and Fair Hearing. Procedures The Contractor shall provide specific information regarding member grievance, appeal and State fair hearing procedures and timeframes to members, as well as providers and subcontractors at the time they enter a contract with the Contractor. This information shall be included in the Member Handbook as described in Section 4.4.1. The information provided shall be approved by OMPP in accordance with Section 4.5, and, as required under 42 CFR 438.10(g)(1), include the following:  ▪ The right to file grievances and appeals;  ▪ The requirements and timeframes for filing a grievance or appeal;  ▪ The availability of assistance in the filing process;  ▪ The toll-free numbers that the member can use to file a grievance or appeal by phone;  ▪ The fact that, if requested by the member and under certain circumstances: 1) benefits will continue if the member files an appeal or requests a FSSA fair hearing within the specified timeframes; and 2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member; The right to request an External Review by an Independent Review Organization of decisions listed in 4.9.4; and  ▪ For a FSSA fair hearing:  • The right to a hearing;  • The method for obtaining a hearing; and  • The rules that govern representation at the hearing.

Member Notice of Grievance, Appeal and Fair Hearing. Procedures The Contractor shall provide specific information regarding member grievance, appeal and State fair hearing procedures and timeframes to members, as well as providers and subcontractors at the time they enter a contract with the Contractor. This information shall be included in the Member Handbook as described in Section 4.4.1. The information provided shall be approved by OMPP in accordance with Section 4.5, and, as required under 42 CFR 438.10(g)(1), include the following:  ▪ The right to file grievances and appeals;  ▪ The requirements and timeframes for filing a grievance or appeal;  ▪ The availability of assistance in the filing process;  ▪ The toll-free numbers that the member can use to file a grievance or appeal by phone;  ▪ The fact that, if requested by the member and under certain circumstances: 1) benefits will continue if the member files an appeal or requests a FSSA fair hearing within the specified timeframes; and 2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member; The right to request an External Review by an Independent Review Organization of decisions listed in 4.9.4; and  ▪ For a FSSA fair hearing:  EXHIBIT 1.E HOOSIER HEALTHWISE SCOPE OF WORK • The right to a hearing;  • The method for obtaining a hearing; and  • The rules that govern representation at the hearing.

Member Notice of Grievance, Appeal and Fair Hearing. Procedures The Contractor shall provide specific information regarding member grievance, appeal and State fair hearing procedures and timeframes to members, as well as providers and subcontractors at the time they enter a contract with the Contractor. This information shall be included in the Member Handbook as described in Section 4.4.1. The information provided shall be approved by OMPP in accordance with Section 4.5, and, as required under 42 CFR 438.10(g)(1), include the following:   The right to file grievances and appeals;   The requirements and timeframes for filing a grievance or appeal;   The availability of assistance in the filing process;   The toll-free numbers that the member can use to file a grievance or appeal by phone;   The fact that, if requested by the member and under certain circumstances: 1) benefits will continue if the member files an appeal or requests a FSSA fair hearing within the specified timeframes; and 2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member; The right to request an External Review by an Independent Review Organization of decisions listed in 4.9.4; and   For a FSSA fair hearing:  o The right to a hearing;  o The method for obtaining a hearing; and  o The rules that govern representation at the hearing.