Common use of Member Notification Clause in Contracts

Member Notification. The Contractor shall provide Members written notice of an Adverse Benefit Determination in writing consistent with 42 C.F.R Part 438.404 and 438.10. The notice must explain the following: 1. The Adverse Benefit Determination the Contractor has made or intends to make; 2. The reasons for the Adverse Benefit Determination, including the right of the Member to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the Member’s Adverse Benefit Determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; 3. The Member's right to request an appeal of the Contractor’s adverse benefit determination, including information on exhausting the Contractor’s one level of appeal described at § 438.402(b) and the right to request a State Fair Hearing; 4. The procedures for exercising the rights specified in this subsection; 5. The circumstances under which an appeal process can be expedited and how to request an expedited appeal; and 6. The Member's right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services. The notice(s) as described within this subsection must be mailed within the following timeframes: 1. For termination, suspension, or reduction of previously authorized Medicaid-covered services, at least ten (10) calendar days prior to the date of the Adverse Benefit Determination; 2. For denial of payment, including denial of payment that may result in Member financial liability, at the time of any action affecting the claim; 3. For standard service authorization decisions that deny or limit services, within ten (10) calendar days of the date of the Adverse Benefit Determination.

Member Notification. ‌ The Contractor shall provide Members written notice of an Adverse Benefit Determination in writing consistent with 42 C.F.R Part 438.404 and 438.10. The notice must explain the following: 1. The Adverse Benefit Determination the Contractor has made or intends to make; 2. The reasons for the Adverse Benefit Determination, including the right of the Member to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the Member’s Adverse Benefit Determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; 3. The Member's right to request an appeal of the Contractor’s adverse benefit determination, including information on exhausting the Contractor’s one level of appeal described at § 438.402(b) and the right to request a State Fair Hearing; 4. The procedures for exercising the rights specified in this subsection; 5. The circumstances under which an appeal process can be expedited and how to request an expedited appeal; and 6. The Member's right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services. The notice(s) as described within this subsection must be mailed within the following timeframes: 1. For termination, suspension, or reduction of previously authorized Medicaid-covered services, at least ten (10) calendar days prior to the date of the Adverse Benefit Determination; 2. For denial of payment, including denial of payment that may result in Member financial liability, at the time of any action affecting the claim; 3. For standard service authorization decisions that deny or limit services, within ten (10) calendar days of the date of the Adverse Benefit Determination.