Reconsideration of Eligibility Determination Sample Clauses

Reconsideration of Eligibility Determination. Qualifications • Beneficiaries determined not eligible for the drug card and/or transitional assistance may request reconsideration of eligibility determination. • Applicant provides timely written notice (that is, notice within 5 business days of the Applicant’s identification of ineligibility due to data submitted on the form) to beneficiaries who are determined to be ineligible for the drug card and/or transitional assistance. The notice must describe the reason identified for ineligibility and contain information on the beneficiary’s right to a reconsideration of the determination and instructions on accessing the reconsideration process. Finally, the notice must inform the beneficiary of his or her option of enrolling in the approved program without access to transitional assistance. • The reconsideration process will be conducted by an independent entity through a contract administered by CMS and will include a review of the beneficiary’s enrollment form and any other documentation required to successfully review each individual case. • The Applicant must communicate with the reconsideration contractor and respond in a timely manner to requests for information, such as copies of enrollment forms. • The eligibility decision from the reconsideration process is final. If the denial is reversed, the enrollment will be effective beginning with the 1st of the month following the positive eligibility determination from reconsideration, AND, if eligible for transitional assistance, the amount of available transitional assistance dollars (in year 2005) relates directly to the month in which the sponsor received the original, complete enrollment form for transitional assistance. The reconsideration contractor will notify the beneficiary by written notice, and CMS by submitting a transaction to enroll as appropriate. • Applicant will be notified by CMS of individuals determined eligible for the drug discount card and/or transitional assistance. • If the denial is upheld, the reconsideration contractor will notify the beneficiary in writing of its decision. Application Requirements • Describe your procedures for notifying beneficiaries of a determination that they are ineligible for transitional assistance and/or the discount card program and advising them of their reconsideration rights. Such notice must be provided within 5 business days of your organization’s receipt of the CMS eligibility determination reply. • Describe your procedures for communicating with...