Grievance and Appeal System definition

Grievance and Appeal System means the processes the Contractor implements to handle Appeals of an Adverse Benefit Determination and Grievances, as well as the processes to collect and track information about them. Health Insuring Organization (HIO) means a county operated entity that in exchange for Capitation Payments, covers services for beneficiaries:

Grievance and Appeal System means the processes the MCO or DBM must implement in accordance with 42 C.F.R. Part 438, Subpart F, to handle enrollee grievances and appeals, as well as the processes to collect and track information about them.

Grievance and Appeal System means the processes a BHO implements to handle appeals of adverse benefit determinations and grievances as well as the processes to collect and track information about them. The BHO must establish the grievance and appeal system and meet the requirements of 42 C.F.R. Sec. 438, Subpart F (2017).

Examples of Grievance and Appeal System in a sentence

• The Contractor must provide reports on the Grievance and Appeal System as required in the AHCCCS Grievance and Appeal System Reporting Guide available on the AHCCCS website.

• UHA, participating providers and subcontractors are to comply with UHA’s Grievance and Appeal System requirements as outlined policies, the CCO Contract, OAR 410-141-3875 through OAR 410-141-3915, OAR 410-120-1860 and 42 CFR§438.400 through §438.424.

• This Technical Advisory is intended to facilitate Prepaid Inpatient Health Plan (PIHP) compliance with the Medicaid Enrollee Grievance and Appeal System requirements contained in Part 11, 6.3.1 of the Medicaid Managed Specialty Supports and Services contract with the Michigan Department of Health and Human Services (MDHHS).

• The Contractor shall have in place a written Grievance and Appeal System process for subcontractors, enrollees and non-contracted providers, which define their rights regarding disputed matters with the Contractor.

• The Contractor shall provide the following information regarding the Grievance and Appeal System for GFS/FBG funded Contracted Services to all Subcontractors: The toll-free numbers to file oral Grievances and Appeals.

More Definitions of Grievance and Appeal System

Grievance and Appeal System means the processes the MCO imple- ments to handle appeals of adverse benefit determinations and grievan- ces, as well as the processes to collect and track information about them.

Grievance and Appeal System means the overall system that includes Grievances and Appeals handled by the Contractor and access to the Administrative Hearing system.

Grievance and Appeal System means the processes the PAHP implements to handle appeals of an adverse benefit determination and grievances, as well as the processes to collect and track information about them.

Grievance and Appeal System means a comprehensive system that includes a grievance process, an appeal process, and access to the Commonwealth’s fair hearing system. Health Care Effectiveness Data and Information Set (HEDIS™) means a national performance improvement tool developed by the National Committee for Quality Assurance (NCQA) and used to measure performance across six domains of care. Health Information means any Health Information provided and/or made available by the Department to a Trading Partner, and has the same meaning as the term “Health Information” as defined by 45 C.F.R. Part 160.103. Health Insurance Portability and Accountability Act (HIPAA) of 1996, and the implementing regulations (45 C.F. R. Sections 142, 160, 162, and 164), all as may be amended. Health Maintenance Organization (HMO) is a licensed entity in the Commonwealth pursuant to KRS 304.38, et seq. Health Risk Assessment (HRA) refers to a standardized screening tool used by the Department’s contracted MCOs to collect information on an Enrollee’s health status, including mental health and substance use disorders(s). Additionally, other information that is collected includes, but is not limited to Enrollee demographics, personal and family medical history, and lifestyle. The Contractor shall use the assessment to identify need for health, behavioral health or community services and to determine when to conduct a more comprehensive Enrollee Needs Assessment to identify Enrollees who are in need of care management. HHS Transaction Standard Regulation means 45 C.F.R., at Title 45, Parts 160 and 162, as may be amended.

Grievance and Appeal System means the processes the Contractor implements to handle appeals of Adverse Benefit Determinations and Grievances, as well as the processes to collect and track information about them. (42 C.F.R. § 438.400 to § 438.424).

Grievance and Appeal System has the meaning provided for “Grievance System” in OAR 410-141-3500.

Grievance and Appeal System means the processes a Behavioral Health Organization (BHO) implements to handle appeals of adverse benefit determinations and grievances as well as the processes to collect and track information about them. The BHO must establish the grievance and appeal system and meet the requirements of 42 CFR § 438 Subpart F.