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 shall incorporate all of the Grievance and Appeal System requirements found in this Contract into its written policies and procedures for Grievances and Appeals.

• When a member requests disenrollment for cause, the member must use the Contractor’s Grievance and Appeal System process for the request and the Contractor shall issue a decision no later than 30 days from the date of the request.

• Also, these pests would more quickly select for genetic resistance to the remaining tools growers have, as growers would have one fewer chemistry to rotate or layer to prevent spores from developing fungicide- resistance.

• A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s Grievance and Appeal System procedures that must be exhausted before filing for a State Fair Hearing, and the availability of an expert medical opinion from an external organization pursuant to section 6.1.45, and the availability of a second opinion at the STATE’s expense during a State Fair Hearing.

• 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.

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 process the Contractor implements to handle Appeals of an Adverse Benefit Determination, Grievances, as well as the process to collect and track information about them. Health Care-Acquired Condition (HAC) means a condition occurring in any inpatient hospital setting, defined as a HAC by the Secretary of Health and Human Services under Section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program identified in the State Plan as described in Section 1886(D)(4)(D)(ii) and (iv) of the Act; other than Deep Vein Thrombosis(DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients. Health Insurer Fee (HIF) means the annual fee the Contractor is required to pay pursuant to Section 9010 of the Patient Protection and Affordable Care Act. 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 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 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.