XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION Sample Clauses

XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION. 25.1. CONTRACTOR shall utilize COUNTY’S designated grievance and appeal system for resolving disputes and grievances including discrimination grievances, and issuing Notices of Adverse Benefit Determinations (NOABDS) pursuant to current state and federal guidelines. 25.2. CONTRACTOR shall not discourage the filing of grievances and clients do not need to use the term “grievance” for a complaint to be captured as an expression of dissatisfaction and, therefore, a grievance. 25.3. Aligned with MHSUDS IN 18-010E and 42 C.F.R. §438.404, the appropriate and delegated Notice of Adverse Benefit Determination (NOABD) must be issued by CONTRACTOR within the specified timeframes using the template provided by the COUNTY.
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XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION. 25.1. CONTRACTOR shall utilize COUNTY’S designated grievance and appeal system for resolving disputes and grievances including discrimination grievances, and issuing Notices of Adverse Benefit Determinations (NOABDS) pursuant to current state and federal guidelines. 25.2. CONTRACTOR shall not discourage the filing of grievances and clients do not need to use the term “grievance” for a complaint to be captured as an expression of dissatisfaction and, therefore, a grievance.
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XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION. In Process A. All grievances (as defined by 42 C.F.R. § 438.400) and complaints received by Contractor must be immediately forwarded to the Compliance Officer or other designated persons via a secure method (e.g., electronic health record, encrypted email or by fax) to allow ample time for the Quality Management staff to acknowledge receipt of the grievance and complaints and issue appropriate responses. B. Contractor shall not discourage the filing of grievances and clients do not need to use the term “grievance” for a complaint to be captured as an expression of dissatisfaction and, therefore, a grievance. C. Aligned with MHSUDS IN 18-010E and 42 C.F.R. §438.404, the appropriate and delegated Notice of Adverse Benefit Determination (NOABD) must be issued by Contractor within the specified timeframes using the template provided by the County. D. Contractor shall participate in County-hosted trainings on grievances and appeals, change of provider, and NORADs. E. NOABDs must be issued to clients anytime the Contractor has made or intends to make an adverse benefit determination that includes the reduction, suspension, or termination of a previously authorized service and/or the failure to provide services in a timely manner. The notice must have a clear and concise explanation of the reason(s) for the decision as established by DHCS and the County. The Contractor must inform the County immediately after issuing a NOABD. F. Procedures and timeframes for responding to grievances, issuing, and responding to adverse benefit determinations, appeals, and state hearings must be followed as per 42 C.F.R., Part 438, Subpart F (42 C.F.R. §§ 438.400 – 438.424). G. Contractor must provide clients any reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal such as auxiliary aids and interpreter services. H. Contractor must maintain records of grievances and appeals and must review the information as part of its ongoing monitoring procedures. The record must be accurately maintained in a manner accessible to the County and available upon request to DHCS.
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XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION. 32.1. CONTRACTOR shall utilize COUNTY’S designated grievance and appeal system for resolving disputes and grievances including discrimination grievances, and issuing Notices of Adverse Benefit Determinations (NOABDS) pursuant to current state and federal guidelines.
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XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION. 16.1.1. CONTRACTOR shall utilize COUNTY’S designated grievance and appeal system for resolving disputes and grievances including discrimination grievances and issuing Notices of Adverse Benefit Determinations (NOABDS) pursuant to current state and federal guidelines. 16.1.2. CONTRACTOR shall not discourage the filing of grievances and clients do not need to use the term “grievance” for a complaint to be captured as an expression of dissatisfaction and, therefore, a grievance. 16.1.3. Aligned with MHSUDS 18-010E and 42 C.F.R. § 438.404, the appropriate and delegated Notice of Adverse Benefit Determination (NOABD) must be issued by CONTRACTORs within the specified timeframes using the template provided by the COUNTY. 16.1.4. NOABDs must be issued to clients anytime the CONTRACTOR has made or intends to make an adverse benefit determination that includes the reduction, suspension, or termination of a previously authorized service and/or the failure to provide services in a timely manner. The notice must have a clear and concise explanation of the reason(s) for the decision as established by DHCS and the COUNTY. The CONTRACTOR must inform the COUNTY immediately after issuing a NOABD.
Sample 1

Related to XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

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