Notice of Adverse Action Process Sample Clauses

Notice of Adverse Action Process. The Contractor shall notify the requesting provider and shall provide written notice to enrolled (on the date of service) members whenever rendering an adverse decision. The contractor has the option to send the enrollee notice as an explanation of benefits statement or as a notice of adverse action. Any statement or notice must be in accordance with the definitions, content of notice, and required timeframes listed below. a. Definition of Adverse Action – Consistent with 42 CFR § 438.400, adverse action refers to the: i. Denial or limited authorization of a service authorization request; including the type or level of service; or ii. Reduction, suspension, or termination of a previously authorized service; iii. Denial in whole or in part of a payment for a covered service for an enrolled member (except where the provider’s claim is denied for technical reasons including but not limited to prior authorization rules, referral rules, late filing, invalid codes, etc); or iv. Failure by the Contractor to render a decision within the timeframes required in this Contract; or v. The denial of an enrollee’s request to exercise his right under 42 CFR § 438.52(b)(2)(ii) to obtain services outside of the network.