Procedures for an Expedited Appeal. (A) When an Enrollee or Provider requests an expedited resolution of an Appeal, the Contractor shall inform the Enrollee or Provider of the limited time available for the Enrollee to present evidence and allegations of fact or law in person and in writing. (B) The Contractor shall ensure that punitive action is not taken against a Provider who either requests an expedited resolution to an Appeal or supports an Enrollee’s Appeal. (C) The Contractor shall give Enrollees any reasonable assistance in making an expedited appeal. Reasonable assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (D) The Contractor shall acknowledge receipt of the request for expedited Appeal resolution either orally or in writing and explain to the Enrollee the process that must be followed to resolve the Appeal. (E) The Contractor shall ensure that the individuals who make the decision on an Appeal are individuals who: (1) were not involved in any previous level of review or decision-making; and (2) if deciding any of the following, are health care professionals who have appropriate clinical expertise, as determined by the Department, in treating the Enrollee’s condition or disease: (i) an Appeal of a denial that is based on lack of Medical Necessity; or (ii) an Appeal that involved clinical issues.
Appears in 6 contracts
Samples: Chip Dentaquest Amendment 2, Chip Select Health Amendment 1, Chip Premier Access Dental Contract Amendment 2
