State Fair Hearings for Members Sample Clauses

State Fair Hearings for Members. A Member may request a State Fair Hearing if they are dissatisfied with an Adverse Benefit Determination that has been taken by the CONTRACTOR and the Member has exhausted the CONTRACTOR’s internal Appeal process, within ninety (90) Calendar Days of the final decision by the CONTRACTOR. The Representative, the estate representative of a deceased Member, or a Provider acting on behalf of the Member and with the Member’s written consent, may request a State Fair Hearing on behalf of the Member. The CONTRACTOR shall provide the HCA/Fair Hearings Bureau, the HCA Medical Assistance Division, the Member and/or the Member’s Representative(s) with a summary of evidence (SOE) within seven (7) Calendar Days after receipt of a request for hearing but no later than fifteen (15) Business Days prior to the initially scheduled hearing. The SOE must contain copies of all documentation used to make the CONTRACTOR’s decision, and it must explain the reasons for the Adverse Benefit Determination and address all of the Member’s concerns. The SOE must refer to all relevant State and federal statutes and regulations used to make the decision. Upon request and no later than seven (7) Calendar Days after receiving the request, the CONTRACTOR shall provide the Member and/or the Member’s Representative (with written consent of the Member) access to the Member’s case file and provide copies of documents contained therein without charge. The CONTRACTOR shall appear with appropriate clinical personnel at all scheduled State Fair Hearings concerning its clinical determinations to present evidence as justification for its determination regarding the disputed benefits and/or services. The CONTRACTOR shall have its legal counsel appear at all scheduled State Fair Hearings for which the CONTRACTOR has received notification that the Member has legal counsel and when HCA provides it with not less than seven (7) Calendar Days’ notice that legal representation will be required. The CONTRACTOR shall comply with all determinations rendered as a result of State Fair Hearings. Nothing in this section shall limit the remedies available to HCA or the federal government relating to any noncompliance by the CONTRACTOR with a State Fair Hearing determination or by the CONTRACTOR’s refusal to provide disputed services. The CONTRACTOR may initiate recovery procedures against the Member, if the Adverse Benefit Determination is upheld after a State Fair Hearing, to recoup the cost of any service required t...
Sample 1Sample 2Sample 3See All (4)
AutoNDA by SimpleDocs
State Fair Hearings for Members. A Member may not file a grievance with the state. A Member shall exhaust the internal Appeal process with the Contractor prior to requesting a State Fair Hearing. The Contractor, the Member, or the Member’s representative or legal representative of the Member’s estate shall be parties to the hearing as provided in 907 KAR 17:010(5). A Member may request a State Fair Hearing if he or she is dissatisfied with an adverse benefit determination that has been taken by the Contractor within one hundred and twenty (120) days of the final appeal decision by the Contractor as provided for in 42 CFR 438.408. A Member may request a State Fair Hearing for an adverse benefit determination taken by the Contractor that denies or limits an authorization of a requested service or reduces, suspends, or terminates a previously authorized service. The standard timeframe for reaching a decision in a State Fair Hearing is found in KRS Chapter 13B. Failure of the Contractor to comply with the State Fair Hearing requirements of the state and federal Medicaid law in regard to an adverse benefit determination taken by the Contractor or to appear and present evidence will result in an automatic ruling in favor of the Member. The Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Member's health condition requires, but not later than 72 hours from the date the Contractor receives notice reversing the determination, if the services were not furnished while the appeal was pending and the State Fair Hearing results in a decision to reverse the Contractor’s decision to deny, limit, or delay services. The Contractor shall pay for disputed services received by the Member while the appeal was pending and the State Fair Hearing reverses a decision to deny authorization of the services. The Department shall provide for an expedited State Fair Hearing within three (3) days of a request for an appeal that meets the requirements of an expedited appeal after a denial by the Contractor.
Sample 1Sample 2
State Fair Hearings for Members. A Member may not file a grievance with the state. A Member shall exhaust the internal Appeal process with the Contractor prior to requesting a State Fair Hearing. The Contractor, the Member, or the Member’s representative or legal representative of the Member’s estate shall be parties to the hearing as provided in 907 KAR 17:010(5). A Member may request a State Fair Hearing if he or she is dissatisfied with an Action that has been taken by the Contractor within forty- five (45) days of the final appeal decision by the Contractor as provided for in 907 KAR 17:010. A Member may request a State Fair Hearing for an Action taken by the Contractor that denies or limits an authorization of a requested service or reduces, suspends, or terminates a previously authorized service. The standard timeframe for reaching a decision in a State Fair Hearing is found in KRS Chapter 13B. Failure of the Contractor to comply with the State Fair Hearing requirements of the state and federal Medicaid law in regard to an Action taken by the Contractor or to appear and present evidence will result in an automatic ruling in favor of the Member. The Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Member's health condition requires if the services were not furnished while the appeal was pending and the State Fair Hearing results in a decision to reverse the Contractor’s decision to deny, limit, or delay services. The Contractor shall pay for disputed services received by the Member while the appeal was pending and the State Fair Hearing reverses a decision to deny authorization of the services. The Department shall provide for an expedited State Fair hearing within three (3) days of a request for an appeal that meets the requirements of an expedited appeal after a denial by the Contractor.
Sample 1Sample 2

Related to State Fair Hearings for Members

  • Restricted Employment for Certain State Personnel Contractor acknowledges that, pursuant to Section 572.069 of the Texas Government Code, a former state officer or employee of a state agency who during the period of state service or employment participated on behalf of a state agency in a procurement or contract negotiation involving Contractor may not accept employment from Contractor before the second anniversary of the date the Contract is signed or the procurement is terminated or withdrawn.

  • 200 Domestic Preferences for Procurements As appropriate and to the extent consistent with law, the non-Federal entity should, to the greatest extent practicable under a Federal award, provide a preference for the purchase, acquisition, or use of goods, products, or materials produced in the United States (including but not limited to iron, aluminum, steel, cement, and other manufactured products). The requirements of this section must be included in all subawards including all contracts and purchase orders for work or products under this award. For purposes of 2 CFR Part 200.322, “Produced in the United States” means, for iron and steel products, that all manufacturing processes, from the initial melting stag through the application of coatings, occurred in the United States. Moreover, for purposes of 2 CFR Part 200.322, “Manufactured products” means items and construction materials composed in whole or in part of non-ferrous metals such as aluminum, plastics and polymer-based products such as polyvinyl chloride pipe, aggregates such as concrete, glass, including optical fiber, and lumber. Pursuant to the above, when federal funds are expended by ESC Region 8 and TIPS Members, Vendor certifies that to the greatest extent practicable Vendor will provide a preference for the purchase, acquisition, or use of goods, products, or materials produced in the United States (including but not limited to iron, aluminum, steel, cement, and other manufactured products). Does vendor agree? Yes

  • Contractor Hearing Board 1. If there is evidence that the Contractor may be subject to debarment, the Department will notify the Contractor in writing of the evidence which is the basis for the proposed debarment and will advise the Contractor of the scheduled date for a debarment hearing before the Contractor Hearing Board.

Time is Money Join Law Insider Premium to draft better contracts faster.