Common use of PROVIDER COMPLAINT AND APPEAL PROCEDURES Clause in Contracts

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. 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.