Recipient Rights and Grievance/Appeals Sample Clauses

Recipient Rights and Grievance/Appeals. The CMHSP shall establish an Office of Recipient Rights in accordance with all of the provisions of Section 755 of the Michigan Mental Health Code and corresponding administrative rules and for substance abuse, Section 6321 of
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Recipient Rights and Grievance/Appeals. The PIHP shall adhere to the requirements stated in the MDCH Grievance and Appeal Technical Requirement, which is an attachment to this contract (Attachment P 6.3.2.1) in addition to provisions specified in 42 CFR 438.100. Individuals enrolled in Medicaid must be informed of their right to an administrative hearing if dissatisfaction is expressed at any point during the rendering of state plan services. While PIHPs may attempt to resolve the dispute through their local processes, the local process must not supplant or replace the individual’s right to file a hearing request with MDCH. The PIHP's grievance or complaint process may, and should, occur simultaneously with MDCH’s administrative hearing process, as well as with the recipient rights process. The PIHP shall follow fair hearing guidelines and protocols issued by the MDCH. The PIHP and all affiliated CMHSPs must maintain an Office of Recipient Rights in accordance with all of the provisions of Section 755 of the Michigan Mental Health Code and for substance abuse, Section 6321 of P.A. 365 of 1978, and corresponding administrative rules. The PIHP must notify the requesting provider of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the provider need not be in writing. The PIHPs must maintain records of grievances and appeals.
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Recipient Rights and Grievance/Appeals. The CMHSP shall establish an Office of Recipient Rights in accordance with all of the provisions of Section 755 of the Michigan Mental Health Code and corresponding administrative rules and for substance abuse, Section 6321 of P.A. 365 of 1978, and corresponding administrative rules. The Community Mental Health Service Program (CMHSP) shall assure that, within the first 90 days of employment, the Recipient Rights Office Director, and all Rights Office staff shall attend, and successfully complete, the Basic Skills Training programs offered by the Department's Office of Recipient Rights. In addition, all Rights Office staff must comply with the requirements delineated in Attachment C.6.3.2.3.A. None of the requirements in this paragraph shall apply to Rights Office clerical staff unless they are involved in processing complaints. The Community Mental Health Service Program (CMHSP) shall assure that, within the first 180 days of employment Executive Directors hired by a CMHSP shall be required to attend a Recipient Rights training focused on the role of the Executive Director relative to the Recipient Rights protection and investigation system.
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Recipient Rights and Grievance/Appeals. The PIHP shall adhere to the requirements stated in the MDCH Grievance and Appeal Technical Requirement, which is an attachment to this contract (Attachment P 6.3.2.1) in addition to provisions specified in 42 CFR 438.100. Individuals enrolled in Medicaid must be informed of their right to an administrative hearing if dissatisfaction is expressed at any point during the rendering of state plan services. While PIHPs may attempt to resolve the dispute through their local processes, the local process must not supplant or replace the individual’s right to file a hearing request with MDCH. The PIHP's grievance or complaint process may, and should, occur simultaneously with MDCH’s administrative hearing process, as well as with the recipient rights process. The PIHP shall follow fair hearing guidelines and protocols issued by the MDCH. The PIHP and all affiliated CMHSPs must maintain an Office of Recipient Rights in accordance with all of the provisions of Section 755 of the Michigan Mental Health Code and for substance abuse, Section 6321 of P.A. 365 of 1978, and corresponding administrative rules. The CMHSPs shall ensure that there is a signed agreement between the CMHSP Office of Recipient Rights, the DHS Bureau of Child and Adult Licensing (BCAL), DHS Child Protective Services (CPS) and MDHS Adult Protective Services (APS) regarding reporting and investigation of suspected abuse, neglect, and exploitation in programs operated or contracted with the PIHP or CMHSP. The CMHSP Office of Recipient Rights shall assure that the semi-annual and annual recipient rights data reports required by MCL 330.1755(5)(j) and MCL 330.1755(6) are submitted to the PIHP Quality Assessment and Performance Improvement Program (QAPIP) in addition to other entities and individuals specified in law. The PIHP must notify the requesting provider of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the provider need not be in writing. The PIHPs must maintain records of grievances and appeals.
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Recipient Rights and Grievance/Appeals. The CMHSP shall establish an Office of Recipient Rights in accordance with all of the provisions of Section 755 of the Michigan Mental Health Code and corresponding administrative rules and for substance abuse, Section 6321 of P.A. 365 of 1978, and corresponding administrative rules. The CMHSP shall make reasonable efforts to obtain a signed agreement between the CMHSP Office of Recipient Rights, the DHS Bureau of Child and Adult Licensing (BCAL), and MDHS Adult Protective Services (APS) regarding reporting and investigation of suspected abuse, neglect, and exploitation in programs operated or contracted with the CMHSP. The CMHSP Office of Recipient Rights shall assure that the semi-annual and annual recipient rights data reports required by MCL 330.1755(5)(j) and MCL 330.1755(6) are submitted to the PIHP Quality Assessment and Performance Improvement Program (QAPIP) in addition to other entities and individuals specified in law.
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Recipient Rights and Grievance/Appeals. 36 6.3.3. Information Requirements 37 6.4 Provider Network Services 38 6.4.1 Provider Procurement 40 6.4.2 Subcontracting 40
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Recipient Rights and Grievance/Appeals. The PIHP shall adhere to the requirements stated in the MDCH Grievance and Appeal Technical Requirement, which is an attachment to this contract (Attachment P 6.3.2.1) in addition to provisions specified in 42 CFR 438.100. Individuals enrolled in Medicaid must be informed of their right to an administrative hearing if dissatisfaction is expressed at any point during the rendering of state plan services. While PIHPs may attempt to resolve the dispute through their local processes, the local process must not supplant or replace the individual’s right to file a hearing request with MDCH. The PIHP's grievance or complaint process may, and should, occur simultaneously with MDCH’s administrative hearing process, as well as with the recipient rights process. The PIHP shall follow fair hearing guidelines and protocols issued by the MDCH. Each CMHSP is required to have an Office of Recipient Rights (XXX) that has been found to be in substantial compliance with recipient rights protection standards by the MDCH’s Office of Recipient Rights. Accordingly, the PIHP has no responsibility to conduct oversight activity with regards to the XXX(s) operated by CMHSPs in the PIHP’s provider network. However, a PIHP that has information or belief regarding a CMHSP’s lack of compliance with requirements for operating a recipient right’s protection system shall provide that information to the MDCH’s XXX for follow-up and action. The PIHP must notify the requesting provider of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the provider need not be in writing. The PIHP must maintain records of grievances and appeals.
Sample 1
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Recipient Rights and Grievance/Appeals. The CMHSP shall establish an Office of Recipient Rights in accordance with all of the provisions of Section 755 of the Michigan Mental Health Code and corresponding administrative rules and for substance abuse, Section 6321 of P.A. 365 of 1978, and corresponding administrative rules. The CMHSP shall make reasonable efforts to obtain a signed agreement between the CMHSP Office of Recipient Rights, the DHS Bureau of Child and Adult Licensing (BCAL), and MDHS Adult Protective Services (APS) regarding reporting and investigation of suspected abuse, neglect, and exploitation in programs operated or contracted with the CMHSP. The CMHSP Office of Recipient Rights shall assure that the semi-annual and annual recipient rights data reports required by MCL 330.1755(5)(j) and MCL 330.1755(6) are submitted to the PIHP Quality Assessment and Performance Improvement Program (QAPIP) in addition to other entities and individuals specified in law. The Community Mental Health Service Program (CMHSP) shall assure that, within the first three months of employment, the Rights Officer/Advisor and any alternate(s) shall attend and successfully complete the Basic Skills Training programs offered by the Department's Office of Recipient Rights. Within one (1) year of the effective date of employment, as training slots are available, Executive Directors hired by a CMHSP shall be required to attend a Recipient Rights training focused on the role of the Executive Director relative to the Recipient Rights protection and investigation system, when such a training is developed and made available by MDCH. In addition, every three (3) years during their employment, the Rights Officer/Advisor and any alternate(s) must complete a Recipient Rights Update training as specified by the Department The Community Mental Health Services Program shall assure that all contractual agreements with service providers, who: (1) are required by the Mental Health Code to implement their rights system or, (2) through contractual agreement are required to implement their own rights investigation system, include language which requires staff appointed as Rights Officers/Advisors (and those identified as their alternates) to attend and successfully complete the Basic Skills Training programs offered by the Department's Office of Recipient Rights.
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Related to Recipient Rights and Grievance/Appeals

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • Your Grievance and Appeals Rights If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) ◼ Amount owed to providers: $7,540 ◼ Plan pays $7,490 ◼ Patient pays $50 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance $0 Limits or exclusions $30 Total $50 Managing type 2 diabetes (routine maintenance of a well-controlled condition) ◼ Amount owed to providers: $5,400 ◼ Plan pays $4,760 ◼ Patient pays $640 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $300 Coinsurance $300 Limits or exclusions $40 Total $640 These examples are based on coverage for an individual plan. Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

  • Employee Rights Grievance Procedure 7.1 Definition of a Grievance A grievance is defined as a dispute or disagreement as to the interpretation or application of the specific terms and conditions of this Agreement.

  • COMPLAINT AND GRIEVANCE PROCEDURE 1. When a member of the bargaining unit has any grievance or complaint, he shall forthwith convey to his immediate superior, orally with or without a member of the Association Executive or in writing, all facts relative to the grievance and/or complaint. The member and the superior shall make every attempt to resolve the problem at this preliminary stage.

  • PROFESSIONAL GRIEVANCE PROCEDURE A. A claim by a teacher, the Association, or the Board of Education that there has been a violation, misinterpretation or misapplication of specific provisions of this Agreement may be processed as a grievance as hereinafter provided.

  • COMPLAINTS AND GRIEVANCES 22.01 It is the mutual desire of the parties to this Agreement that reasonable and legitimate complaints and grievances of employees shall be dealt with as quickly as possible.

  • DISPUTES AND GRIEVANCES Section 1. This Agreement is intended to provide close cooperation between management and labor. Each of the Unions will assign a representative to this Project for the purpose of completing the construction of the Project economically, efficiently, continuously, and without interruptions, delays, or work stoppages.

  • Employee Grievance Procedure 91. An employee having a grievance may first discuss it with the employee's immediate supervisor, or the next level in management, to try to work out a satisfactory solution in an informal manner. The employee may have a representative(s) at this discussion.

  • Recognition of Union Stewards and Grievance Committee In order to provide an orderly and speedy procedure for the settling of grievances, the Employer acknowledges the rights and duties of the Union Stewards. The Xxxxxxx shall assist any Employee, which the Xxxxxxx represents, in preparing and presenting her grievance in accordance with the grievance procedure.

  • Policy Grievance – Union Grievance The Union may institute a grievance alleging a general misinterpretation or violation of this Agreement by the Employer by submitting a written grievance at Step No. 1 within twenty (20) days after the circumstances have occurred. This section shall not apply to disciplinary grievances or application of competitive clauses under this Agreement.

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