Complaint determination definition
Examples of Complaint determination in a sentence
The file shall include: • Date the complaint was filed; • Copy of the complaint, if written; • Date of receipt of and copy of the member’s acknowledgment, if any; • Complaint determination including the date of the determination and the titles of the personnel and credentials of clinical personnel who reviewed the complaint; • Date and copy of the member’s appeal; • The titles and credentials of clinical staff, of the personnel who reviewed the appeal.
The effective date of the disenrollment is suspended if the Participant files a Complaint within ten (10) days of receiving notification of disenrollment and requests a DHS Fair Hearing within ten (10) days of receiving the notice of the Complaint determination.
For issues related to disputed services, Enrollees must have received a negative Complaint determination from the Contractor confirming the decision of a Participating Provider to deny those services.
The fle shall include: • Date the complaint was fled; • Copy of the complaint, if written; • Date of receipt of and copy of the member’s acknowledgment, if any; • Complaint determination including the date of the determination and the titles of the personnel and credentials of clinical personnel who reviewed the complaint; • Date and copy of the member’s appeal; • The titles and credentials of clinical staff, of the personnel who reviewed the appeal.
Enrollees may seek redress of a negative Complaint determination about a PCP’s decision to deny a referral, or to deny or reduce a benefit or service, or to authorize a service for less than requested, simultaneously through Contractor’s internal process and the State fair hearing process.