PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must develop, implement and maintain a provider complaint system. The complaint and appeal procedures must be in compliance with all applicable state and federal law or regulations. All Member complaints and/or appeals of an adverse determination requested by the enrollee, or any person acting on behalf of the enrollee, or a physician or provider acting on behalf of the enrollee must comply with the provisions of this Article. Modifications and amendments to the complaint system must be submitted to HHSC no later than 30 days prior to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts or in the provider manual.
7.6.3 HMO’s complaint and appeal process cannot contain provisions requiring a provider to submit a complaint or appeal to HHSC for resolution in lieu of the HMO’s process.
7.6.4 HMO must establish mechanisms to ensure that network providers have access to a person who can assist providers in resolving issues relating to claims payment, plan administration, education and training, and complaint procedures.
7.6.5 Beginning August 1, 2004, providers must file appeals or adjustment requests within 120 days from the date of disposition, which is the date of the Remittance and Status (R&S) report on which the last action on the claims appears; the deadline is applicable to both paper and electronic submissions.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. HMO's complaint and appeal process cannot contain provisions requiring a PROVIDER to submit a complaint or appeal to TDH for resolution in lieu of the HMO's process.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must develop, implement and maintain a provider complaint system. The complaint and appeal procedures must be in compliance with all applicable state and federal law or regulations. All Member complaints and/or appeals of an adverse determination requested by the enrollee, or any person acting on behalf of the enrollee, or a physician or provider acting on behalf of the enrollee must comply with the provisions of this Article. Modifications and amendments to the complaint system must be submitted to TDH no later than 30 days prior to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts or in the provider manual.
7.6.3 HMO's complaint and appeal process cannot contain provisions requiring a Member to submit a complaint or appeal to TDH for resolution in lieu of the HMO's process.
7.6.4 HMO must establish mechanisms to ensure that network providers have access to a person who can assist providers in resolving issues relating to claims payment, plan administration, education and training, and complaint procedures.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must develop implement and maintain a provider complaint system which must be in compliance with all applicable state and federal law or regulations. Modifications and amendments to the complaint system must be submitted to TDH no later than 30 days prior to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts or in the provider manual.
7.6.3 HMO's complaint and appeal process cannot contain provisions requiring a Member to submit a complaint or appeal to TDH for resolution in lieu of the HMO's process. 1999 Renewal Contract Xxxxxx Service Area August 9, 1999 63
7.6.4 HMO must establish mechanisms to ensure that network providers have access to a person who can assist providers in resolving issues relating to claims payment, plan administration, education and training, and complaint procedures.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.7.1 HMO must develop, implement and maintain a provider complaint system. The complaint and appeal procedure must be in compliance with all applicable State and federal law or regulations. Modifications and amendments to the complaint system must be submitted to TDHS no later than 30 days prior to the implementation of the modification or amendment.
7.7.2 HMO must include the provider complaint and appeal procedure in all network provider contracts or in the provider manual.
7.7.3 HMO s complaint and appeal process cannot contain provisions referring the complaint or appeal to TDHS for resolution. HMO providers and other subcontractors are not "contractors" for purposes of 40 TAC Sec. 79.1601. TDHS/HMO CONTRACT August 11, 1999 60 67
7.7.4 HMO must establish mechanisms to ensure that network providers have access to a person who can assist providers in resolving issues relating to claims payment, plan administration, education and training, and complaint procedures.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must establish a written provider complaint and appeal procedure for network providers. HMO must submit the written complaint and appeal procedure to TDH by Phase II of Readiness Review. The complaint and appeals procedure must be the same for all providers and must comply with Texas Insurance Code, Art. 20A.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts.
7.6.3 HMO's complaint and appeal process cannot contain provisions referring the complaint or appeal to TDH for resolution.
7.6.4 HMO must establish mechanisms to ensure that network providers have access to a person who can assist providers in resolving issues relating to claims payment, plan administration, education and training, and complaint procedures.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must establish a written provider complaint and appeal procedure for network providers. HMO must submit the written complaint and appeal procedure to TDH by Phase II of Readiness Review. The complaint and appeals procedure must be the same for all providers and must comply with Texas Insurance Code, Art. 20A.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts or in the provider manual.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must develop, implement and maintain a provider complaint system. HMO must submit the written complaint and appeal procedure to TDH by Phase II of Readiness Review. The complaint and appeals procedures must be in compliance with all applicable state and federal law or regulations. All Member complaints and/or appeals of an adverse determination requested by a physician or provider acting on behalf of the enrollee must comply with the provisions of this Article. Modifications and amendments to the complaint system must be submitted to TDH no later than 30 days prior to the implementation of the modification or amendment.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must develop, implement and maintain a provider complaint system. The complaint and appeal procedures must be in compliance with all applicable state and federal law or regulations. All Member complaints and/or appeals of an adverse determination requested by the enrollee, or any person acting on behalf of the enrollee, or a physician or provider acting on behalf of the enrollee must comply with the provisions of this Article. Modifications and amendments to the complaint system must be submitted to HHSC no later than 30 days prior to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts or in the provider manual.
PROVIDER COMPLAINT AND APPEAL PROCEDURES. 7.6.1 HMO must develop, implement and maintain a provider complaint system. The complaint and appeals procedure must be in compliance with all applicable state and federal law or regulations. All Member complaints and/or appeals of an adverse determination request by the enrollee, or any person acting on behalf of the enrollee, or physician or provider acting on behalf of the enrollee must comply with the 61 Dallas Service Area Contract 68 provisions of this Article. Modifications and amendments to the complaint system must be submitted to TDH no later than 30 days prior to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in all network provider contracts.
7.6.3 HMO's complaint and appeal process cannot contain provisions requiring a provider to submit a complaint or appeal to TDH for resolution in lieu of the HMO's process.
7.6.4 HMO must establish mechanisms to ensure that network providers have access to a person who can assist providers in resolving issues relating to claims payment, plan administration, education and training, and complaint procedures.
