Common use of XXXXXXXXXX, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION Clause in Contracts

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.

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 25.1. CONTRACTOR shall utilize COUNTY’S 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 appeal system for resolving disputes and issue appropriate responsesgrievances including discrimination grievances, and issuing Notices of Adverse Benefit Determinations (NOABDS) pursuant to current state and federal guidelines. B. Contractor 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. C. . 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 CONTRACTOR within the specified timeframes using the template provided by the CountyCOUNTY. D. Contractor shall participate in County-hosted trainings on grievances and appeals, change of provider, and NORADs. E. 25.4. NOABDs must be issued to clients anytime the Contractor 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 CountyCOUNTY. The Contractor CONTRACTOR must inform the County COUNTY immediately after issuing a NOABD. F. 25.5. Procedures and timeframes for responding to grievances, issuing, 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 25.6. 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 25.7. 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 COUNTY and available upon request to DHCS. 25.8. CONTRACTOR shall not require a beneficiary to file a Discrimination Grievance with the CONTRACTOR before filing the grievance directly with DHCS Office of Civil Rights and the U.S. Health and Human Services Office for Civil Rights. 25.9. CONTRACTOR shall have access to the COUNTY designated discrimination grievance coordinator to Answer questions and provide appropriate assistance to CONTRACTOR staff and members regarding the CONTRACTOR’S state and federal nondiscrimination legal obligations. Advise the CONTRACTOR about nondiscrimination best practices and accommodating persons with disabilities. Investigate and process any Americans with Disabilities Act, Section 504 of the Rehabilitation Act, section 1557 of the Affordable Care Act, and/or Gov. Code section 11135 grievances received by the CONTRACTOR.

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 County’s 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 NORADsNOABDs. 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, 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.

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 16.1.1. CONTRACTOR shall utilize COUNTY’S 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 appeal system for resolving disputes and issue appropriate responsesgrievances including discrimination grievances and issuing Notices of Adverse Benefit Determinations (NOABDS) pursuant to current state and federal guidelines. B. Contractor 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. C. 16.1.3. 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 CONTRACTORs within the specified timeframes using the template provided by the CountyCOUNTY. D. Contractor shall participate in County-hosted trainings on grievances and appeals, change of provider, and NORADs. E. 16.1.4. NOABDs must be issued to clients anytime the Contractor 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 CountyCOUNTY. The Contractor CONTRACTOR must inform the County COUNTY immediately after issuing a NOABD. F. 16.1.5. 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 16.1.6. CONTRACTOR must provide clients with 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 16.1.7. 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 COUNTY and available upon request to DHCS. 16.1.8. CONTRACTOR shall not require a beneficiary to file a Discrimination Grievance with the CONTRACTOR before filing the grievance directly with DHCS Office of Civil Rights and the U.S. Health and Human Services Office for Civil Rights. 16.1.9. CONTRACTOR shall have access to the COUNTY designated discrimination grievance coordinator to Answer questions and provide appropriate assistance to CONTRACTOR staff and members regarding the CONTRACTOR’S state and federal nondiscrimination legal obligations. Advise the CONTRACTOR about nondiscrimination best practices and accommodating persons with disabilities. Investigate and process any Americans with Disabilities Act, Section 504 of the Rehabilitation Act, section 1557 of the Affordable Care Act, and/or Gov. Code section 11135 grievances received by the CONTRACTOR. DRAFT

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 County’s 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 NORADsNOABDs. 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, 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.