Standard Appeals Process Clause Samples
Standard Appeals Process. All of the staff at Rocky Mountain PACE share responsibility with you, your family or caregiver in providing you the comprehensive health care services identified in your Plan of Care as authorized by the Interdisciplinary Team. You, your family or caregiver are encouraged to contact a member of the Interdisciplinary Team when you have a disagreement with Rocky Mountain PACE’s non-coverage, reduction in services, or of nonpayment for a service. If we deny your request for a service or for payment of a claim, we will give you a written copy of this information on the appeals process, including a form that you may use to request your appeal. You may also make your appeal known verbally, and PACE staff will document and submit your request for an appeal. The Rocky Mountain PACE Quality Assurance Manager or designee will respond to you in writing within two working days, stating that your appeal has been received. A person not involved in our initial decision to deny your request for a service or to pay a claim will reevaluate your appeal. The reviewer will be an appropriately credentialed and impartial individual who was not involved in the original action and does not have a stake in the outcome of the appeal. You or your authorized representative may present or submit to us relevant facts and/or evidence for review, either in person or in writing for consideration during the appeal process. Within thirty (30) calendar days of receiving the appeal, Rocky Mountain PACE will notify you by certified mail of the appeals decision. A copy of the notification will be kept in your file. Rocky Mountain PACE may not stop or reduce services while your appeal is pending. If the appeal is not resolved in your favor, you may be charged for the cost of the services. Rocky Mountain PACE has an expedited appeal process for situations in which you, or your family or caregiver believe your life, health, or ability to regain maximum function would be seriously jeopardized, absent provision of the service in dispute: • You or your authorized representative may present or submit relevant facts and/or evidence for review, to support your request for an expedited appeal. • The Quality Assurance Department will respond to your request for an expedited appeal within 24 hours and notify you if your appeal has been found to meet the criteria for expediting an appeal. • For expedited appeals you will be notified in writing, in the same manner as described in the standard appeal process,...
Standard Appeals Process. The standard Appeal process includes the following:
6.4.5.1. Standard Appeals for Actions communicated on a Notice of Action – continued services not requested.
6.4.5.2. An Enrollee who disagrees with a decision or Action communicated on a Notice of Action may file an Appeal orally or in writing.
6.4.5.3. All of the following shall apply:
6.4.5.3.1. The Enrollee shall file the Appeal within 90 calendar days from the date on the Notice of Action.
6.4.5.3.2. The Contractor shall confirm receipt of Appeals in writing within five (5) business days.
6.4.5.3.3. The Contractor shall send the Enrollee a written notice of the resolution within 45 calendar days of receiving the Appeal that includes: • The Contractor’s decision and date of decision; • The reason for the decision; and • The right to request a Fair Hearing if the Enrollee disagrees with the decision.
6.4.5.4. The Contractor may extend the timeframe up to 14 additional calendar days if the Enrollee requests an extension or the Contractor can demonstrate that it needs additional information and that the added time is in the Enrollee’s interest. If the extension is not requested by the Enrollee or the Enrollee’s proxy, the Contractor shall provide a written notice to the Enrollee stating the reason for the extension.
Standard Appeals Process. 8.4.4. 1 An Enrollee who disagrees with a decision or Action communicated on a Notice of Action may file an Appeal orally or in writing.
Standard Appeals Process