Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions. 4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter. 4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint. 4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider. 4.9.7.5 As a part of the Provider Complaint System, the Contractor shall: 4.9.7.5.1 Allow Providers thirty (30) Calendar Days to file a written complaint; 4.9.7.5.2 Allow providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal. 4.9.7.5.3 Allow a provider that has exhausted the care management organization ´s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s fees, shall be shared equally by the parties. 4.9.7.5.4 For all claims that are initially denied or underpaid by a care management organization but eventually determined or agreed to have been owed by the care management organization to a provider of health care services, the care management organization shall pay, in addition to the amount determined to be owed, interest of 20 percent per annum, calculated from 15 days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment. 4.9.7.5.5 All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider. 4.9.7.5.6 Require that the reason for the complaint is clearly documented; 4.9.7.5.7 Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing); 4.9.7.5.8 Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems; 4.9.7.5.9 Identify a staff person specifically designated to receive and process Provider Complaints; 4.9.7.5.10 Thoroughly investigate each GF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and 4.9.7.5.11 Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process. 4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA § 00-0-000, XXXX § 00-00-00 and OCGA § 50-13-15. 4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information: 4.9.7.7.1 A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge; 4.9.7.7.2 Identification of the Action being appealed and the issues that will be addressed at the hearing; 4.9.7.7.3 A specific statement of why the Provider believes the Contractor’s Action is wrong; and 4.9.7.7.4 A statement of the relief sought. 4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s address where a Provider’s request for an Administrative Law Hearing should be sent in accordance with OCGA § 49-4-153(e).
Appears in 1 contract
Samples: Contract for Provision of Services (Amerigroup Corp)
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 : • Allow Providers thirty (30) Calendar Days to file a written complaint;
4.9.7.5.2 ; • Allow providers Providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.
4.9.7.5.3 . • Allow a provider Provider that has exhausted the care management organization ´s organization’s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section O.C.G.A. § 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider Provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider Provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s attorney’s fees, shall be shared equally by the parties.
4.9.7.5.4 . • For all claims that are initially denied or underpaid by a care management organization the Contractor but eventually determined or agreed to have been owed by the care management organization Contractor to a provider of health care services, the care management organization Contractor shall pay, in addition to the amount determined to be owed, interest of 20 twenty percent (20%) per annumannum (based on simple interest calculations), calculated from 15 fifteen (15) business days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
4.9.7.5.5 . • All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider.
4.9.7.5.6 Provider. • Require that the reason for the complaint is clearly documented;
4.9.7.5.7 ; • Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
4.9.7.5.8 ; • Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
4.9.7.5.9 ; • Identify a staff person specifically designated to receive and process Provider Complaints;
4.9.7.5.10 ; • Thoroughly investigate each GF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and
4.9.7.5.11 and • Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA O.C.G.A. § 0049-04-000153, XXXX O.C.G.A. § 0050-0013-00 13 and OCGA O.C.G.A. § 50-13-15.
4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
4.9.7.7.1 : • A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
4.9.7.7.2 ; • Identification of the Action being appealed and the issues that will be addressed at the hearing;
4.9.7.7.3 ; • A specific statement of why the Provider believes the Contractor’s Action is wrong; and
4.9.7.7.4 and • A statement of the relief sought.
4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s address where a Provider’s request for an Administrative Law Hearing should be sent in accordance with OCGA O.C.G.A. § 49-4-153(e).
Appears in 1 contract
Samples: Contract for Provision of Services
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions, including Proposed Actions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafterwithin sixty (60) Calendar Days of Contract Award.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard hard-copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 Allow Providers thirty forty-five (3045) Calendar Days to file a written complaint;
4.9.7.5.2 Allow providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.
4.9.7.5.3 Allow a provider that has exhausted the care management organization ´s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s fees, shall be shared equally by the parties.
4.9.7.5.4 For all claims that are initially denied or underpaid by a care management organization but eventually determined or agreed to have been owed by the care management organization to a provider of health care services, the care management organization shall pay, in addition to the amount determined to be owed, interest of 20 percent per annum, calculated from 15 days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
4.9.7.5.5 All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider.
4.9.7.5.6 Require that the reason for the complaint is clearly documented;
4.9.7.5.7 Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
4.9.7.5.8 4.9.7.5.3 Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
4.9.7.5.9 4.9.7.5.4 Identify a staff person specifically designated to receive and process Provider Complaints;
4.9.7.5.10 4.9.7.5.5 Thoroughly investigate each GF GHF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and
4.9.7.5.11 4.9.7.5.6 Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA § 0049-04-000, XXXX § 00-00-00 and OCGA § 50-13-15153.
4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
4.9.7.7.1 A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
4.9.7.7.2 Identification of the Action being appealed and the issues that will be addressed at the hearing;
4.9.7.7.3 A specific statement of why the Provider believes the Contractor’s Action is wrong; and
4.9.7.7.4 A statement of the relief sought.
4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s following address where a Provider’s request for an Administrative Law Hearing should can be sent in accordance with OCGA § 49sent: Department of Community Health Legal Services Section Division of Medical Assistance Txx Xxxxxxxxx Xxxxxx, XX-00xx Xxxxx Xxxxxxx, Xxxxxxx 00000-4-153(e).0000
Appears in 1 contract
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 : · Allow Providers thirty (30) Calendar Days to file a written complaint;
4.9.7.5.2 ; · Allow providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.
4.9.7.5.3 . · Allow a provider that has exhausted the care management organization ´s organization’s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s attorney’s fees, shall be shared equally by the parties.
4.9.7.5.4 . · For all claims that are initially denied or underpaid by a care management organization but eventually determined or agreed to have been owed by the care management organization to a provider of health care services, the care management organization shall pay, in addition to the amount determined to be owed, interest of 20 percent per annum, calculated from 15 days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
4.9.7.5.5 . · All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider.
4.9.7.5.6 . · Require that the reason for the complaint is clearly documented;
4.9.7.5.7 ; · Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
4.9.7.5.8 ; · Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
4.9.7.5.9 ; · Identify a staff person specifically designated to receive and process Provider Complaints;
4.9.7.5.10 ; · Thoroughly investigate each GF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and
4.9.7.5.11 and · Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA § 00-0-000, XXXX § 00-00-00 and OCGA § 50-13-15.
4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
4.9.7.7.1 : · A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
4.9.7.7.2 ; · Identification of the Action being appealed and the issues that will be addressed at the hearing;
4.9.7.7.3 ; · A specific statement of why the Provider believes the Contractor’s Action is wrong; and
4.9.7.7.4 and · A statement of the relief sought.
4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s address where a Provider’s request for an Administrative Law Hearing should be sent in accordance with OCGA § 49-4-153(e).
Appears in 1 contract
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 : · Allow Providers thirty (30) Calendar Days to file a written complaint;
4.9.7.5.2 ; · Allow providers Providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.
4.9.7.5.3 . · Allow a provider Provider that has exhausted the care management organization ´s organization’s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section O.C.G.A. § 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider Provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider Provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s attorney’s fees, shall be shared equally by the parties.
4.9.7.5.4 . · For all claims that are initially denied or underpaid by a care management organization the Contractor but eventually determined or agreed to have been owed by the care management organization Contractor to a provider of health care services, the care management organization Contractor shall pay, in addition to the amount determined to be owed, interest of 20 twenty percent (20%) per annumannum (based on simple interest calculations), calculated from 15 fifteen (15) business days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
4.9.7.5.5 . · All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider.
4.9.7.5.6 Provider. · Require that the reason for the complaint is clearly documented;
4.9.7.5.7 ; · Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
4.9.7.5.8 ; · Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
4.9.7.5.9 ; · Identify a staff person specifically designated to receive and process Provider Complaints;
4.9.7.5.10 ; · Thoroughly investigate each GF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and
4.9.7.5.11 and · Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA O.C.G.A. § 0049-04-000153, XXXX O.C.G.A. § 0050-0013-00 13 and OCGA O.C.G.A. § 50-13-15.
4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
4.9.7.7.1 : · A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
4.9.7.7.2 ; · Identification of the Action being appealed and the issues that will be addressed at the hearing;
4.9.7.7.3 ; · A specific statement of why the Provider believes the Contractor’s Action is wrong; and
4.9.7.7.4 and · A statement of the relief sought.
4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s address where a Provider’s request for an Administrative Law Hearing should be sent in accordance with OCGA O.C.G.A. § 49-4-153(e).
Appears in 1 contract
Samples: Contract for Provision of Services (Wellcare Health Plans, Inc.)
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions, including Proposed Actions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafterwithin sixty (60) Calendar Days of Contract Award.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard hard-copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 Allow Providers thirty forty-five (3045) Calendar Days to file a written complaint;
4.9.7.5.2 Allow providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.
4.9.7.5.3 Allow a provider that has exhausted the care management organization ´s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s fees, shall be shared equally by the parties.
4.9.7.5.4 For all claims that are initially denied or underpaid by a care management organization but eventually determined or agreed to have been owed by the care management organization to a provider of health care services, the care management organization shall pay, in addition to the amount determined to be owed, interest of 20 percent per annum, calculated from 15 days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
4.9.7.5.5 All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider.
4.9.7.5.6 Require that the reason for the complaint is clearly documented;
4.9.7.5.7 Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
4.9.7.5.8 4.9.7.5.3 Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
4.9.7.5.9 4.9.7.5.4 Identify a staff person specifically designated to receive and process Provider Complaints;
4.9.7.5.10 4.9.7.5.5 Thoroughly investigate each GF GHF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and
4.9.7.5.11 4.9.7.5.6 Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA § 0049-04-000, XXXX § 00-00-00 and OCGA § 50-13-15153.
4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
4.9.7.7.1 A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
4.9.7.7.2 Identification of the Action being appealed and the issues that will be addressed at the hearing;
4.9.7.7.3 A specific statement of why the Provider believes the Contractor’s Action is wrong; and
4.9.7.7.4 A statement of the relief sought.
4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s following address where a Provider’s request for an Administrative Law Hearing should can be sent in accordance with OCGA § 49sent: Department of Community Health Legal Services Section Division of Medical Assistance Xxx Xxxxxxxxx Xxxxxx, XX-00xx Xxxxx Xxxxxxx, Xxxxxxx 00000-4-153(e).0000
Appears in 1 contract
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s 's policies, procedures, or any aspect of a Contractor’s 's administrative functions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s 's Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 Allow Providers thirty (30) Calendar Days to file a written complaint;
4.9.7.5.2 Allow providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal.. Revised 5/19/2008
4.9.7.5.3 Allow a provider that has exhausted the care management organization ´s organization's internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the care management organization and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney ´s attorney's fees, shall be shared equally by the parties.
4.9.7.5.4 For all claims that are initially denied or underpaid by a care management organization but eventually determined or agreed to have been owed by the care management organization to a provider of health care services, the care management organization shall pay, in addition to the amount determined to be owed, interest of 20 percent per annum, calculated from 15 days after the date the claim was submitted. A care management organization shall pay all interest required to be paid under this provision or Code Section 33-24-59.5 automatically and simultaneously whenever payment is made for the claim giving rise to the interest payment.
4.9.7.5.5 All interest payments shall be accurately identified on the associated remittance advice submitted by the care management organization to the provider.
4.9.7.5.6 Require that the reason for the complaint is clearly documented;
4.9.7.5.7 Require that Providers exhaust the Contractor’s 's internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);
4.9.7.5.8 Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;
4.9.7.5.9 Identify a staff person specifically designated to receive and process Provider Complaints;; Revised 5/19/2008
4.9.7.5.10 Thoroughly investigate each GF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s 's written policies and procedures; and
4.9.7.5.11 Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.
4.9.7.6 In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA § 00-0-000, XXXX § 00-00-00 and OCGA § 50-13-15.
4.9.7.7 The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:
4.9.7.7.1 A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;
4.9.7.7.2 Identification of the Action being appealed and the issues that will be addressed at the hearing;
4.9.7.7.3 A specific statement of why the Provider believes the Contractor’s 's Action is wrong; and
4.9.7.7.4 A statement of the relief sought.
4.9.7.8 DCH has delegated its statutory authority to receive hearing requests to the Contractor. The Contractor shall include with the Notice of Adverse Action the Contractor’s 's address where a Provider’s 's request for an Administrative Law Hearing should be sent in accordance with OCGA § 49-4-153(e).
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