Provider Grievances and Appeals. The Contractor shall implement a process to ensure that a Provider shall have the right to file an internal appeal with the Contractor regarding denial of a health care service or claim for reimbursement, provider payment or contractual issues. The Department shall provide a standard Provider Grievance Form to be used by the Contractor to initiate its provider grievance process. Appeals received from Providers that are on the Member’s behalf for denied services with requisite consent of the Member are deemed Member appeals and not subject to this Section.
Provider Grievances and Appeals. Subcontractor and Health Plan agree to handle provider appeals and grievances promptly, consistently, fairly, and incompliance with state and federal law and Department requirements. Subcontractor and Health Plan shall have in place a provider appeals and grievance system, distinct from that offered to Covered Persons, that includes a grievance process for providers to bring issues to Subcontractor and Health Plan, an appeals process for Provider to challenge certain Subcontractor and Health Plan decisions, and information regarding access to a state level review through the Office of Administrative hearings. Subcontractor and Health Plan shall be transparent with providers regarding its appeals and grievance processes and procedures. Subcontractor and Health Plan shall submit Subcontractor’s and Health Plan’s Provider Grievances and Appeals Policy to the Department for review 120 days after Contract Award. Subcontractor and Health Plan shall submit any significant policy changes to the Department for review at least 60 calendar days before implementing the changes. Subcontractor and Health Plan shall have a process to and staff capable of reviewing provider Grievance and Appeal outcomes to identify trends, review existing operational or clinical opportunities to improve the provider experience. The administrative guide located at xxx.xxxxxxxxxxx.xxx will describe grievance and appeal process(es). Provider agrees to complete all applicable grievance and appeal processes before seeking other legal or administrative remedies under State or federal law.
Provider Grievances and Appeals. The Contractor shall implement a process to ensure that all Appeals from Providers are reviewed. Every Appeal filed shall be recorded in a written record and logged with the following details: date, nature of Appeal, identification of the individual filing the Appeal, identification of the individual recording the appeal, disposition of the Appeal, corrective action required and date resolved. Provider grievances or appeals shall be resolved within thirty (30) calendar days. If the grievance or appeal is not resolved within thirty (30) days, the Contractor shall request a fourteen (14) day extension from the Provider. If the Provider 107 requests the extension, the extension shall be approved by the Contractor. The Contractor shall ensure that there is no discrimination against a Provider solely on the grounds that the Provider filed an Appeal or is making an informal Grievance. The Contractor shall monitor and evaluate Provider Grievances and Appeals. The Contractor shall submit quarterly reports to the Department regarding the number, type and outcomes of Provider Grievances and appeals. A Provider shall have the right to file an appeal with the Contractor regarding provider payment or contractual issues. A Provider does not have standing to request a State Fair Hearing. A request from a Provider for a State Fair Hearing upon a Member’s behalf, may only do so with the express consent signed by the Member pursuant to 907 KAR 17:010 and if the Action resulted in a denial, reduction or suspension of the service. A Provider may not request a State Fair Hearing upon a Member’s behalf regarding payment.
Provider Grievances and Appeals. The administrative guide located at xxx.xxxxxxxxxxx.xxx will describe grievance and appeal process(es). Provider agrees to complete all applicable grievance and appeal processes before seeking other legal or administrative remedies under State or federal law.
Provider Grievances and Appeals. 6.3. PO must bring any claim or dispute relating to this Contract in accordance with Plan’s Provider Grievances and Appeals policies, as provided under the Plan Provider Manual. Pursuant to the North Carolina Contract, PO acknowledges that it must exhaust all such review and appeal rights under the Plan Provider Manual before it may seek any other legal or administrative remedy under state or federal law.
Provider Grievances and Appeals. United agrees to handle provider appeals and grievances promptly, consistently, fairly, and incompliance with state and federal law and Department requirements. United shall have in place a provider appeals and grievance system, distinct from that offered to Covered Persons, that includes a grievance process for providers to bring issues to United, an appeals process for Provider to challenge certain United decisions, and information regarding access to a state level review through the Office of Administrative hearings. United shall be transparent with providers regarding its appeals and grievance processes and procedures. United shall submit United’s Provider Grievances and Appeals Policy to the Department for review 120 days after Contract Award. United shall submit any significant policy changes to the Department for review at least 60 calendar days before implementing the changes. United shall have a process to and staff capable of reviewing provider Grievance and Appeal outcomes to identify trends, review existing operational or clinical opportunities to improve the provider experience. The administrative guide located at xxx.xxxxxxxxxxx.xxx will describe applicable grievance and appeal process(es). Provider agrees to complete all applicable grievance and appeal processes before seeking other legal or administrative remedies under State or federal law.
Provider Grievances and Appeals
