Common use of State Fair Hearing Process Clause in Contracts

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 telephone or in person. The CCO is responsible for absorbing any telephone/travel expenses incurred. The Contractor shall comply with the Division’s hearing process, no more or less and in the same manner as is required for all other Mississippi Medicaid evidentiary hearings. The Contractor shall comply with the Division’s fair hearing decision. The Division’s decision in these matters shall be final and shall not be subject to appeal by the Contractor.

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 telephone or in person. The CCO is responsible for absorbing any telephone/travel expenses incurred. The Contractor shall comply with the Division’s hearing process, no more or less and in the same manner as is required for all other Mississippi Medicaid evidentiary hearings. The Contractor shall comply with the Division’s fair hearing decision. The Division’s decision in these matters shall be final and shall not be subject to appeal by the Contractor.

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) 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) 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 telephone or in person. The CCO is responsible for absorbing any telephone/travel expenses incurred. The Contractor shall comply with the Division’s hearing process, no more or less and in the same manner as is required for all other Mississippi Medicaid evidentiary hearings. The Contractor shall comply with the Division’s fair hearing decision. The Division’s decision in these matters shall be final and shall not be subject to appeal by the Contractor.