Common use of State Fair Hearings for Members Clause in Contracts

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 to be continued while the Appeal was pending.

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 HCAHSD/Fair Hearings Bureau, the HCA HSD/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 HSD 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 HSD 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 to be continued while the Appeal was pending.