Common use of XXXXXX OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS Clause in Contracts

XXXXXX OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS. 1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision. 2. A Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint without first exhausting the Plan’s internal Grievance or Appeals process if: a. In the case of an Adverse Decision: SAMPLE i. The Plan or the Plan’s Designee waives the requirement that the internal Grievance process be exhausted before filing a Complaint with the Commissioner; ii. The Plan or the Plan’s Designee has failed to comply with any of the requirements of the internal Grievance process; iii. The Member, the Member’s Representative or Health Care Provider acting on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason. b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s Designee of the Complaint within five working days after the date the Complaint is filed with the Commissioner. b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the Plan’s Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s Designee receives the request for information. 4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final decision on a Complaint: i. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. Within 45 days after a Complaint is filed regarding a Post-Service Claim; and iii. Within 24 hours after a Complaint is filed regarding a Claim Involving Urgent Care.

XXXXXX OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS. 1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision. 2. A Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member may file a Complaint without first exhausting the Plan’s 's internal Grievance or Appeals process if: a. In the case of an Adverse Decision: SAMPLE: i. The Plan or the Plan’s 's Designee waives the requirement that the internal Grievance process be exhausted before filing a Complaint with the Commissioner; ii. The Plan or the Plan’s 's Designee has failed to comply with any of the requirements of the internal Grievance process; iii. The Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason. b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s 's Designee of the Complaint within five working days after the date the Complaint is filed with the Commissioner. b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the Plan’s 's Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s 's Designee receives the request for information. 4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final decision on a Complaint: i. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. Within 45 days after a Complaint is filed regarding a Post-Service Claim; and iii. Within 24 hours after a Complaint is filed regarding a Claim Involving Urgent Care.