State Fair Hearing Process Sample Clauses

State Fair Hearing Process. In accordance with 42 CFR 438.408, the State maintains a fair hearing process which allows members the opportunity to appeal the Contractor’s decisions to the State. Appeal procedures for applicants and recipients of Medicaid are found at 405 IAC 1.1. The State fair hearing procedures include the requirements described in this Section 4.9.5. Members shall first exhaust the Contractor’s grievance and appeals process. The member may request an FSSA fair hearing within sixty (60) calendar days from the date of the Contractor’s decision. The parties to the FSSA fair hearing shall include the Contractor, as well as the member and his or her representative or the representative of a deceased member's estate. The Contractor shall respond to all requests for documentation required for the FSSA fair hearing within the timeframe identified in the request. In addition, if requested by OMPP at least five (5) business days in advance, the Contractor shall send a representative to the FSSA fair hearing to represent the State. Contractor will be subject to the contract compliance remedies set forth in Exhibit 2 for failing to either (i) provide a timely and satisfactory response to documentation required for an appeal or (ii) to represent the State at the FSSA fair hearing upon adequate notice. Adequate notice, at a minimum, requires notice of hearing mailed by the Office of Hearings and Appeal, or in the alternative, a request sent directly to the Compliance Officer by the Office of Medicaid Policy and Planning. If dissatisfied with the outcome of the State fair hearing, the member may request an agency review within ten (10) days of receipt of the administrative law judge’s decision. Pursuant to 405 IAC 1.1-3-1, if the member is not satisfied with the final action after agency review, the member may file a petition for judicial review in accordance with IC 4- 21.5-5. The MCE may request an agency review of a decision made by an administrative law judge, at the Contractor's discretion. The Contractor shall include the FSSA fair hearing process as part of the written internal process for resolution of appeals and shall describe the fair hearing process in the member handbook.

State Fair Hearing Process. In accordance with 42 CFR 438.408, the State maintains a fair hearing process which allows members the opportunity to appeal the Contractor’s decisions to the State. Refer to 405 IAC 1.1 for the appeal procedures for applicants and recipients of Medicaid. Members must first exhaust the Contractor’s grievance and appeals process. The Contractor must timely coordinate the grievance and appeal process. Within one hundred and twenty (120) calendar days of exhausting the Contractor’s internal procedures, the member may request a FSSA fair hearing. The parties to the FSSA fair hearing shall include the Contractor, as well as the member and his or her representative or the representative of a deceased member's estate. If dissatisfied with the outcome of the FSSA fair hearing, the member may request an agency review within ten (10) days of the administrative law judge’s decision. An agency decision may be brought before a judicial review pursuant to 405 IAC 1.1-3-1. The Contractor will be subject to the contract compliance remedies (set forth in Exhibit 2 Contract Compliance and Pay for Outcomes) for failing to provide a timely and satisfactory response to documentation required for an appeal or failure to represent the state at the FSSA fair hearing.

State Fair Hearing Process. In accordance with 42 CFR 438.408, the State maintains a fair hearing process which allows members the opportunity to appeal the Contractor’s decisions to the State. Refer to 405 IAC 1.1 for the appeal procedures for applicants and recipients of Medicaid. Members must first exhaust the Contractor’s grievance and appeals process. Within one hundred and twenty (120) calendar days of exhausting the Contractor’s internal procedures, the member may request a FSSA fair hearing. The parties to the FSSA fair hearing shall include the Contractor, as well as the member and his or her representative or the representative of a deceased member's estate. If dissatisfied with the outcome of the FSSA fair hearing, the member may request an agency review within ten (10) days of the administrative law judge’s decision. An agency decision may be brought before a judicial review pursuant to 405 IAC 1.1-3-1. The Contractor must include the FSSA fair hearing process as part of the written internal process for resolution of appeals and must describe the fair hearing process in the member handbook described in Section 4.4.2.

State Fair Hearing Process. The Contractor shall educate its enrollees of their right to appeal directly to the Division. The enrollee has the right to appeal to the Division at the same time that he appeals to the Contractor; after he has exhausted his appeal rights with the Contractor; or instead of appealing to the Contractor. Any adverse action or appeal that is not resolved wholly in favor of the enrollee by the Contractor may be appealed by the enrollee or the enrollee’s authorized representative to the Division for a fair hearing conducted in accordance with 42 CFR § 431 Subpart E. Adverse actions include reductions in service, suspensions, terminations, and denials. Furthermore, the Contractor’s denial of payment for Mississippi Medicaid covered services and failure to act on a request for services within required timeframes may also be appealed. Appeals must be requested in writing by the enrollee or the enrollee’s representative within thirty (30) days of the enrollee’s receipt of notice of adverse action unless an acceptable reason for delay exists. An acceptable reason shall include, but not be limited to, situations or events where:  Appellant was seriously ill and was prevented from contacting the Contractor.  Appellant did not receive notice of the Contractor’s decision.  Appellant sent the request for appeal to another government agency in good faith within the time limit;  Unusual or unavoidable circumstances prevented a timely filing. Additionally, if the Contractor’s notice is “defective,” i.e., does not contain the required elements, cause may exist. The Division reserves the right to sanction the Contractor per occurrence whenever it is identified that the Contractor has failed to provide notice or provides an incorrect notice of appeal rights. For enrollee appeals, the Contractor is responsible for providing to the Division and to the enrollee an appeal summary describing the basis for the denial. For standard appeals, the appeal summary must be submitted to the Division and the enrollee at least ten (10) calendar days prior to the date of the hearing. For expedited appeals, (that meet the criteria set forth in 42 CFR § 438.410) the appeal summary must be faxed to the Division and faxed or overnight mailed to the enrollee, as expeditiously as the enrollee’s health condition requires, but no later than four (4) business hours after the Division informs the Contractor of the expedited appeal. The Division may require that the CCO attend the hearing either via ...

State Fair Hearing Process. In accordance with 42 CFR 438.408, the State maintains a fair hearing process which the State. Appeal procedures for applicants and recipients of Medicaid are found at 405 IAC 1.1. The State fair hearing procedures include the requirements described in this Section 4.9.5.

State Fair Hearing Process. At any time during the grievance process, per California State law, you may also request a fair hearing from the California Department of Social Services by contacting or writing to:

State Fair Hearing Process. In accordance with 42 CFR 438.408, the State maintains a fair hearing process which allows members the opportunity to appeal the Contractor’s decisions to the State. Refer to 405 IAC 1.1 for the appeal procedures for applicants and recipients of Medicaid. Members must first exhaust the Contractor’s grievance and appeals process. Within one hundred and twenty (120) calendar days of exhausting the Contractor’s internal procedures, the member may request a FSSA fair hearing. The parties to the FSSA fair hearing shall include the Contractor, as well as the member and his or her representative or the representative of a deceased member's estate. If dissatisfied with the outcome of the FSSA fair hearing, the member may request an agency review within ten (10) days of the administrative law judge’s decision. An agency decision may be brought before a judicial review pursuant to 405 IAC 1.1-3-1. EXHIBIT 1. M SCOPE OF WORK The Contractor must include the FSSA fair hearing process as part of the written internal process for resolution of appeals and must describe the fair hearing process in the member handbook described in Section 4.4.2.

State Fair Hearing Process. 5. The FEA is required to provide the DHS and/or the participant’s ICA with any documentation requested for the Wisconsin State Fair Hearing process. This requirement is applicable both when the ICA issues the NOA on behalf of DHS or when the NOA is issued from DHS as a result of a budget amendment, one-time expense request, or other termination, denial, limitation, or reduction of service.