Resolution and Notification Sample Clauses
The 'Resolution and Notification' clause outlines the procedures for addressing and resolving disputes or issues that arise under an agreement, as well as the requirements for formally notifying the involved parties of such matters. Typically, this clause specifies the steps each party must take to communicate concerns, the method and timeline for providing written notice, and the process for seeking resolution, such as negotiation or escalation to higher management. Its core practical function is to ensure that all parties are promptly informed of disputes and have a clear, structured process for resolving them, thereby minimizing misunderstandings and facilitating efficient conflict management.
Resolution and Notification. Basic rule. The Contractor must dispose of each grievance and resolve each appeal, and provide notice, as expeditiously as the
Resolution and Notification. 2.5.5.1 The Contractor shall review each grievance and send a notice of resolution to the enrollee no later than ninety (90) calendar days from the date the Contractor receives the grievance.
2.5.5.2 The Contractor shall hear each appeal and shall send a notice of resolution to the enrollee no later than forty- five (45) calendar days from the date the Contractor receives the appeal.
2.5.5.3 The timeframe for a grievance or appeal may be extended up to fourteen (14) calendar days if the enrollee asks for an extension, or if the Contractor documents that additional documentation is needed and the delay is in the enrollee’s interest. If the timeframe is extended other than at the enrollee’s request, within five (5) business days of the determination to extend, the Contractor shall notify the enrollee, in writing, of the reasons for the delay.
2.5.5.4 The Contractor shall provide written notice of disposition of an appeal. In the case of an expedited appeal, the Contractor shall also provide oral notice by close of business the day of the disposition.
2.5.5.5 The written notice of resolution will include the results of the grievance or appeal process and the date it was completed. If an appeal or grievance is not resolved wholly in favor of an enrollee, the written notice must contain information on the enrollee’s right to request a Medicaid Fair Hearing and how to do so; the right to receive benefits while the fair hearing is pending and how to make that request. The notice must also make the enrollee aware that he or she may be held liable for the cost of those benefits if the fair hearing decision upholds the Contractor’s action.
Resolution and Notification. 1. The Health Plan shall follow Agency guidelines in resolving grievances and appeals as expeditiously as possible, observing required timeframes and taking into account the enrollee’s health condition.
2. A grievance shall be reviewed and notice of results sent to the enrollee no later than ninety (90) calendar days from the date the Health Plan receives it.
3. An appeal shall be heard and notice of results sent to the enrollee no later than forty-five (45) calendar days from the date the Health Plan receives it.
4. The timeframe for a grievance or appeal may be extended up to fourteen (14) calendar days if:
a. The enrollee asks for an extension, or the Health Plan documents that additional information is needed and the delay is in the enrollee’s interest;
b. If the timeframe is extended other than at the enrollee’s request, the Health Plan shall notify the enrollee within five (5) business days of the determination, in writing, of the reason for the delay.
5. The Health Plan shall complete the grievance process in time to accommodate an enrollee’s disenrollment effective date, which can be no later than the first day of the second month after the filing of a request for disenrollment.
6. The Health Plan shall provide written notice of disposition of an appeal. In the case of an expedited appeal denial, the Health Plan also shall provide oral notice by close of business on the day of disposition, and written notice within two (2) calendar days after the disposition in accordance with 42 CFR 438.410(c).
Resolution and Notification. The contractor must resolve each expedited appeal and provide notice, as expeditiously as the enrollee’s health condition requires, within State-established timeframes not to exceed 3 working days after the contractor receives the appeal.
Resolution and Notification. CONTRACTOR shall resolve each appeal and provide notice to enrollee, as expeditiously as the enrollee's health condition requires, within the ADMINISTRATION's established timeframes, which may not exceed forty-five (45) days from the day the CONTRACTOR received the appeal.
Resolution and Notification. INSURER shall resolve each expedited appeal and provide notice, as expeditiously as the enrollee’s health condition requires, and within the ADMINISTRATION established timeframes, which may never exceed three (3) working days after the INSURER received the appeal.
Resolution and Notification. The contractor’s internal grievance procedure may use the timeframes provided in s. 641.511, F.S. as guidelines, unless a shorter time period is otherwise specified in this part. Standard disposition of a grievance must not exceed 90 days from the date the contractor receives the grievance, unless the enrollee requests the extension or the contractor requires additional information and the delay will not prejudice the enrollee’s interest. The extension should not exceed 14 calendar days and the contractor must provide the enrollee written notice of the reason it is requesting a delay. The contractor’s appeal process must provide for a timeframe that is no longer than 45 days from the date the appeal is received by the contractor through resolution. An extension of up to 14 days for both standard and expedited appeals, may be permitted for the same reasons as is permitted for resolution of standard grievances and as detailed in 42 CFR 438.408. The contractor must provide a method for expedited resolution of appeals as expeditiously as required by the enrollee’s condition but in any event, resolution should not exceed 3 working days after receipt of the request for appeal. If the contractor denies a request for an expedited review, it should provide for prompt oral notice of the denial to the enrollee, followed by written notice within 2 calendar days. The contractor must also provide for a transfer of the appeal to the timeframe for standard resolution of the appeal. The contractor must provide written notice of disposition of all appeals. It is recommended that the contractor provide reasonable efforts for oral notice of disposition of expedited appeals. The written notice must contain the results of the resolution process and the date it was completed. If an appeal is not resolved wholly in favor of an enrollee, the written notice must set out the enrollee’s right to request a fair hearing and the process required to make the request and the right to receive benefits while the fair hearing is pending and how to make that request. The notice should also make the enrollee aware that he or she may be held liable for the cost of those benefits if the fair hearing decision upholds the contractor’s action.
Resolution and Notification. Grievances and Appeals (42 CFR §438.408).
i. The Contractor shall resolve each grievance and appeal, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the following timeframes:
a. Standard resolution of grievances: 90 calendar days from the day the Contractor receives the grievance.
b. Standard resolution of appeals: 30 calendar days from the day the Contractor receives the appeal. This timeframe may be extended in the manner described below.
c. Expedited resolution of appeals: 72 hours after the Contractor receives the appeal. This timeframe may be extended under in the manner described below.
Resolution and Notification. Basic Rule: The CCN must dispose of a grievance and provide notice, as expeditiously as the member’s health condition requires, within the timeframes established in § 9.5.3.1 below.
Resolution and Notification. The ap- plicable integrated plan must make in- tegrated reconsidered determinations as expeditiously as the enrollee’s health condition requires but no later than the timeframes established in this section. Integrated reconsidered deter- minations regarding Part B drugs must comply with the timelines governing Part B drugs established in §§ 422.584(d)(1) and 422.590(c) and (e)(2).