Common use of Provider Dispute Resolution Process Clause in Contracts

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, at a minimum: • Informal and formal processes for settlement of Provider Disputes. • Acceptance and usage of this Agreement’s definition of Provider Appeals and Provider Disputes. • Time frames for submission and resolution of Provider Disputes and Provider Appeals. • Processes to provide equitability for all Providers. • Mechanisms and time frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, and the Department. • Establishment of a CHC-MCO Committee to process formal Provider Appeals, which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee members in making decisions. – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, at a minimum: •  Informal and formal processes for settlement of Provider Disputes. •  Acceptance and usage of this Agreement’s definition of Provider Appeals and Provider Disputes. •  Time frames for submission and resolution of Provider Disputes and Provider Appeals. •  Processes to provide equitability for all Providers. •  Mechanisms and time frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, and the Department. •  Establishment of a CHC-MCO Committee to process formal Provider Appeals, which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee members in making decisions. – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, at a minimum: • Informal and formal processes for settlement of Provider Disputes. • Acceptance and usage of this Agreement’s definition of Provider Appeals and Provider Disputes. • Time frames for submission and resolution of Provider Disputes and Provider Appeals. • Processes to provide equitability for all Providers. • Mechanisms and time frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, and the Department. • Establishment of a CHC-MCO Committee to process formal Provider Appeals, which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee members in making decisions. – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, include at a minimum: • Informal and formal processes for settlement of Provider Disputes. • Acceptance and usage of this the Agreement’s definition of Provider Appeals and Provider Disputes. • Time frames for submission and resolution of Provider Disputes and Provider Appeals. • Processes to provide equitability for all Providers. • Mechanisms and time time-frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, Relations and the Department. • Establishment of a CHC-MCO Committee to process formal Provider Appeals, Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee committee members in making decisions. – Documentation of meetings and decisions of the CommitteetheCommittee.

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, include at a minimum: •  Informal and formal processes for settlement of Provider Disputes. •  Acceptance and usage of this the Agreement’s definition of Provider Appeals and Provider Disputes. •  Time frames for submission and resolution of Provider Disputes and Provider Appeals. •  Processes to provide equitability for all Providers. •  Mechanisms and time time-frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, Relations and the Department. •  Establishment of a CHC-MCO Committee to process formal Provider Appeals, Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee committee members in making decisions. – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, include at a minimum: • Informal and formal processes for settlement of Provider Disputes. • Acceptance and usage of this the Agreement’s definition of Provider Appeals and Provider Disputes. • Time frames for submission and resolution of Provider Disputes and Provider Appeals. • Processes to provide equitability for all Providers. • Mechanisms and time time-frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, Relations and the Department. • Establishment of a CHC-MCO Committee to process formal Provider Appeals, Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee committee members in making decisions. – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution Process. The CHC-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The CHC-MCO and the Provider must handle the resolution of all issues regarding the interpretation of Provider Agreements and shall not involve the Department; therefore, Provider disputes and appeals are not within the jurisdiction of the Department’s BHA. Prior to implementation, the CHC-MCO must submit to the Department its policies and procedures for resolution of Provider Disputes and Provider Appeals for approval. The CHC-MCO’s Provider Disputes and Provider Appeals policies and procedures must include, include at a minimum: •  Informal and formal processes for settlement of Provider Disputes. •  Acceptance and usage of this the Agreement’s definition of Provider Appeals and Provider Disputes. •  Time frames for submission and resolution of Provider Disputes and Provider Appeals. •  Processes to provide equitability for all Providers. •  Mechanisms and time time-frames for reporting Provider Appeal decisions to CHC- MCO administration, QM, Provider Relations, Relations and the Department. •  Establishment of a CHC-MCO Committee to process formal Provider Appeals, Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Providers/peers. – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues. – Access to data necessary to assist Committee committee members in making decisions. – Documentation of meetings and decisions of the CommitteetheCommittee.