Common use of Provider Complaint System Clause in Contracts

Provider Complaint System. a. The Health Plan shall establish and maintain a provider complaint system that permits a provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed actions and claims. b. The Health Plan shall include its provider complaint system policies and procedures in its provider handbook as described above. c. The Health Plan shall also distribute the provider complaint system policies and procedures, including claims issues, to out-of-network providers upon request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s website. This summary shall also detail how the provider can request a hard copy from the Health Plan at no charge. d. As a part of the provider complaint system, the Health Plan shall: (1) Have dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider complaint and resolve problems; (2) Identify a staff person specifically designated to receive and process provider complaints; (3) Allow providers forty-five (45) calendar days to file a written complaint for issues that are not about claims; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (4) Thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Health Plan’s written policies and procedures; and (5) Ensure that Health Plan executives with the authority to require corrective action are involved in the provider complaint process. e. The Health Plan shall provide a written notice of the outcome of the review to the provider.

Provider Complaint System. a. The Health Plan shall establish and maintain a provider complaint system that permits a provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed actions and claims. b. The Health Plan shall include its provider complaint system policies and procedures in its provider handbook as described above. c. The Health Plan shall also distribute the provider complaint system policies and procedures, including claims issues, to out-of-network providers upon request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s website. This summary shall also detail how the provider can request a hard copy from the Health Plan at no charge. d. As a part of the provider complaint system, the Health Plan shall: (1) Have dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider complaint and resolve problems; (2) Identify a staff person specifically designated to receive and process provider complaints; (3) Allow providers forty-five (45) calendar days to file a written complaint for issues that are not about claims; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract; (4) Thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Health Plan’s written policies and procedures; and (5) Ensure that Health Plan executives with the authority to require corrective action are involved in the provider complaint process. e. The Health Plan shall provide a written notice of the outcome of the review to the provider.. HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract

Provider Complaint System. a. The Health Plan shall establish and maintain a provider complaint system that permits a provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed actions and claims. b. The Health Plan shall include its provider complaint system policies and procedures in its provider handbook as described above. c. The Health Plan shall also distribute the provider complaint system policies and procedures, including claims issues, to out-of-network providers upon request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s website. This summary shall also detail how the provider can request a hard copy from the Health Plan at no charge. d. As a part of the provider complaint system, the Health Plan shall: (1) Have dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider complaint and resolve problems; (2) Identify a staff person specifically designated to receive and process provider complaints; (3) Allow providers forty-five (45) calendar days to file a written complaint for issues that are not about claims; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract; (4) Thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Health Plan’s written policies and procedures; and (5) Ensure that Health Plan executives with the authority to require corrective action are involved in the provider complaint process. e. The Health Plan shall provide a written notice of the outcome of the review to the provider.. AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract