Common use of Required Content of Notice of Adverse Benefit Determination, Generally Clause in Contracts

Required Content of Notice of Adverse Benefit Determination, Generally. (A) The Contractor’s Notice of Adverse Benefit Determination to an Enrollee shall be in writing and meet the language and format requirements outlined in Article 3.5. (B) All written Notices of Adverse Benefit Determination required by this Contract shall explain that: (1) the Adverse Benefit Determination the Contractor has taken or intends to take; (2) the reason for the Adverse Benefit Determination; (3) the right of the Enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the Enrollee’s Adverse Benefit Determination (such information includes Medical Necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits); (4) the right to request an Appeal of the Adverse Benefit Determination with the Contractor; (5) the procedures for requesting an Appeal; (6) the circumstances under which expedited resolution of an Appeal is available and how to request an expedited Appeal resolution; (7) the timeframe for filing an oral or written Appeal request, which is within 60 calendar days from the date on the Contractor’s Notice of Adverse Benefit Determination; (8) if the Adverse Benefit Determination is to reduce, suspend or terminate previously authorized services, the date the reduction, suspension or termination will become effective; and (i) the Enrollee’s right to request that services continue pending the outcome of an Appeal; (ii) how to request that the services be continued; (iii) that the Enrollee or the Enrollee’s legal guardian or other authorized representative must request continuation of services; (iv) the timeframe for requesting continuation of services, which is the later of the following: within 10 calendar days of the Contractor mailing the Notice of Adverse Benefit Determination, or by the intended effective date of the Contractor’s proposed Adverse Benefit Determination; and (v) that if the Appeal decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of the services.

Required Content of Notice of Adverse Benefit Determination, Generally. (A) The Contractor’s Notice of Adverse Benefit Determination to an Enrollee shall be in writing and meet the language and format requirements outlined in in Article 3.53. (B) All written Notices of Adverse Benefit Determination required by this Contract shall explain that: (1) the Adverse Benefit Determination the Contractor has taken or intends to take; (2) the reason for the Adverse Benefit Determination; (3) the right of the Enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the Enrollee’s Adverse Benefit Determination (such information includes Medical Necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits); (4) the date the Adverse Benefit Determination will become effective when the Adverse Benefit Determination is to terminate, suspend, or reduce a previously authorized Covered Service; (5) the right to request an Appeal of the Adverse Benefit Determination with the Contractor; (56) the procedures for requesting an Appeal; (67) the circumstances under which expedited resolution of an Appeal is available and how to request an expedited Appeal resolution; (7) 8) the timeframe for filing an oral or written Appeal request, which is within 60 calendar days from the date on the Contractor’s Notice of Adverse Benefit Determination; (8) 9) if the Adverse Benefit Determination is to reduce, suspend or terminate previously authorized services, the date the reduction, suspension or termination will become effective; and (i) the Enrollee’s right to request that services continue pending the outcome of an Appeal; (ii) how to request that the services be continued; (iii) that the Enrollee or the Enrollee’s legal guardian or other authorized representative must request continuation of services; (iv) the timeframe for requesting continuation of services, which is the later of the following: within 10 calendar days of the Contractor mailing the Notice of Adverse Benefit Determination, or by the intended effective date of the Contractor’s proposed Adverse Benefit Determination; and (v) that if the Appeal decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of the services.

Required Content of Notice of Adverse Benefit Determination, Generally. (A) The Contractor’s Notice of Adverse Benefit Determination to an Enrollee shall be in writing and meet the language and format requirements outlined in in Article 3.53. (B) All written Notices of Adverse Benefit Determination required by this Contract shall explain that: (1) the Adverse Benefit Determination the Contractor has taken or intends to take; (2) the reason for the Adverse Benefit Determination; (3) the right of the Enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the Enrollee’s Adverse Benefit Determination (such information includes Medical Necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits); (4) the date the Adverse Benefit Determination will become effective when the Adverse Benefit Determination is to terminate, suspend, or reduce a previously authorized Covered Service; (5) the right to request an Appeal of the Adverse Benefit Determination with the Contractor; (56) the procedures for requesting an Appeal; (67) the circumstances under which expedited resolution of an Appeal is available and how to request an expedited Appeal resolution; (78) the Enrollee’s right to have disputed services continue pending resolution of the Appeal of an Adverse Benefit Determination to terminate, suspend or reduce a previously authorized course of treatment that was ordered by an authorized Provider; (9) how to request that the disputed services be continued, and the circumstances under which the Enrollee may be required to pay the cost of these services if the Appeal decision is adverse to the Enrollee, to the extent that they were furnished solely because of this Contract requirement in accordance with 42 CFR 438.420; 438.404(b)(6), and 431.230(b); and (10) the following timeframe for filing an oral Appeal, as applicable: (i) if the Enrollee is not requesting continuation of disputed services pending resolution of an Appeal of an Adverse Benefit Determination to terminate, suspend or written reduce a previously authorized course of treatment that was ordered by an authorized Provider, and the original period covered by the original authorization has not expired, the Enrollee or the Provider, shall file the Appeal request, which is within 60 calendar days from the date on the Contractor’s Notice of Adverse Benefit Determination; (8) if the Adverse Benefit Determination is to reduce, suspend or terminate previously authorized services, the date the reduction, suspension or termination will become effective; and (i) the Enrollee’s right to request that services continue pending the outcome of an Appeal;or (ii) how if the Enrollee is requesting continuation of disputed services pending resolution of an Appeal of an Adverse Benefit Determination to request terminate, suspend or reduce a previously authorized course of treatment that was ordered by an authorized Provider, and the services be continued; (iii) that original period covered by the original authorization has not expired, the Enrollee or Provider shall file the Enrollee’s legal guardian Appeal on or other authorized representative must request continuation of services; (iv) the timeframe for requesting continuation of services, which is before the later of the following: within 10 calendar days of the Contractor mailing the Notice of Adverse Benefit Determination, or by the intended effective date of the Contractor’s proposed Adverse Benefit Determination; and (v) that if the Appeal decision is adverse to the Enrollee, that the Enrollee may be required to pay for the continued services to the extent they were furnished solely because of the request for continuation of the services.: