Grievance and Appeals Process definition

Grievance and Appeals Process means the formal process described in the Benefit Plan and/or in the Provider Manual for the submission of Grievances or requesting review of denials of coverage or utilization review decisions. This process provides for expedited review, which may be requested over the phone, in cases where the State Health Plan Member’s health would be detrimentally affected by a delay of care pending the standard review process.
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Examples of Grievance and Appeals Process in a sentence

  • You agree to cooperate with and assist State Health Plan Members, and other Practitioners if applicable, in our Grievance and Appeals Process.

  • The timeframe for resolution is ninety (90) calendar days from receipt of the grievance as provided in Rhode Island Medicaid Managed Care Grievance and Appeals Process.

  • Should MSHN fail to pay or adequately provide for such additional payment to PROVIDER within the thirty (30) days following receipt of notification from PROVIDER, PROVIDER shall have the right and process of appeal as set forth in the Grievance and Appeals Process defined in the MSHN- SUDSP Manual.

  • All nonclinical disputes, controversies or claims arising out of or under this Agreement, if not resolved through the Plan’s Dispute Resolution (Grievance and Appeals) Process, shall be resolved as set forth in this paragraph.

  • Any dispute not related to claims payment issues between the parties which cannot be resolved pursuant to Administrator’s Provider Grievance and Appeals Process shall be resolved through binding arbitration pursuant to the Commercial Arbitration Rules of the American Arbitration Association.

  • If we determine that you do not meet the criteria for continuity of care and you disagree with our determination, see HPSM’s Grievance and Appeals Process on page 87.

  • If Contractor denies a request for expedited resolution of an appeal, it must transfer the appeal to the timeframe for standard resolution in accordance with Rhode Island Medicaid Managed Care Grievance and Appeals Process and make reasonable efforts to give the member prompt oral notice of the denial, and follow up within two (2) calendar days with written notice.

  • Have the Grievance and Appeals Process in writing and explained to you in a clear and understandable manner before enrollment, at the time of enrollment, at the time when a grievance or appeal is filed and at least annually.

  • Any disputes between the parties that cannot be resolved pursuant to VBH’ Provider Grievance and Appeals Process shall be resolved through binding arbitration pursuant to the Rules of the American Arbitration Association for Arbitration of Commercial Disputes.

  • If, after calling the plan, you feel your needs have not been met, please refer to HPSM’s Grievance and Appeals Process on page 87.