Common use of Reversed Standard Appeal Decisions Clause in Contracts

Reversed Standard Appeal Decisions. (A) If the Contractor or State Fair Hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the standard Appeal or State Fair Hearing was pending, the Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires, but no later than 72 hours from the date it receives notice reversing the determination. (B) If the Contractor or the State Fair Hearing officer reverses a decision to deny authorization of services and the Enrollee received the disputed services while the standard Appeal or State Fair Hearing was pending, the Contractor shall pay for those services in accordance with State policy and regulations.