Grievances and Appeals a. If you have questions about any pediatric dental services received, please first discuss the matter with your Dental Provider. However, if you continue to have concerns, please call Delta Dental’s Customer Service Center. You can also email questions by accessing the “Contact Us” section of the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.
Grievances and Appeals. 19.1 42 C.F.R. § 438.400 defines the term “grievance” to mean an expression of dissatisfaction about any matter other than an Adverse Benefit Determination. It includes, but is not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, failure to respect the beneficiary’s rights regardless of whether remedial action is requested, and the beneficiary’s rights to dispute an extension of time proposed by the MHP to make an authorized decision.
Grievances and Appeals. The MAO shall implement the applicable requirements of 42 CFR 422.562(a)(5), and any subsequent regulatory guidance relating to assistance with Medicaid covered service grievances and appeals as detailed in paragraph 2.14 of this Agreement. The MAO shall submit Grievances and Appeals reports in accordance with the requirements of Attachment 1: Chart of Deliverables and the AHCCCS Grievance System Reporting Guide. AHCCCS shall use these reports for informational purposes only. The MAO shall provide AHCCCS with the following information: A quarterly summary of Part C and Part D pre-service member appeals received and the outcomes of those appeals, A quarterly summary of Medicare Independent Review Entity (IRE) decisions received, and Service level detail on those appeals upheld and overturned (including a description of the action that was appealed).
Grievances and Appeals. No salary adjustments under Section C.4 of this Article may be grieved under this Agreement or under any previous Agreement. This prohibition precludes grievances under all other provisions of this and previous Agreements.
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Grievances and Appeals. All grievances (as defined by 42 C.F.R. § 438.400) and complaints received by Contractor must be immediately forwarded to the County’s BHRS Quality Management Department via a secure method (e.g., 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. 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.
1.12.5.4.1 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.
1.12.5.4.2 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.
Grievances and Appeals. When appropriate, notify the rendering provider of the authorization decision. Notices to providers need not be in writing.
Grievances and Appeals. Insurer shall have a Grievance and Appeal system in place for Enrollees in compliance with 42 CFR 457.1260. The Grievance and Appeal system shall be the same for Title XXI Enrollees and Full-pay Plan Enrollees. Insurer shall establish and maintain policies and procedures for the Grievance and Appeal system, including procedures for expedited Appeals. Insurer shall provide its Grievance and Appeal policies and procedures to FHKC by the date established in the approved implementation plan and at least sixty (60) Calendar Days prior to any proposed changes. The initial policy and procedures and any subsequent changes are subject to approval by FHKC. Insurer shall provide its Grievance and Appeal policies and procedures to Providers and Subcontractors when Insurer engages with such entities or individuals and after any approved changes. Insurer shall ensure individuals making decisions about Grievances and Appeals:
a. Were not involved in any previous level of review or decision-making and are not the subordinate of any such individual;
b. Have the appropriate clinical expertise in treating the Enrollee’s condition or disease when:
i. An Appeal is based on lack of Medical Necessity;
ii. A Grievance is about the denial of an expedited resolution of an Appeal; and
iii. A Grievance or Appeal involves clinical issues.
c. Take all comments, documents, records, and other information submitted by the Enrollee or Enrollee’s representative into account without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. Insurer shall maintain a record of all Grievances and Appeals that includes the following information for each Grievance and Appeal:
a. Date received;
b. Date of each review or review meeting, as applicable;
c. Enrollee name;
d. Nature or general description of the reason for the Grievance or Appeal;
e. Disposition of each level of the Grievance and Appeal process, as applicable;
f. Date of resolution at each level, as applicable; and
g. Documents relevant to each Grievance and Appeal. Insurer shall accurately maintain these records in a manner accessible to FHKC and, upon request, CMS. Insurer shall provide FHKC with a quarterly Grievances and Appeals report. The Grievances and Appeals report shall include:
a. A summary analysis of the Grievances and Appeals that includes:
i. Appeal response timeliness as a percentage of Appeals in the reporting quarter that were closed timely. Appeals closed in the qua...
Grievances and Appeals. Participants and Preferred Providers may submit grievances and appeal qualified ACO decisions in accordance with the ACO Appeals Policy, available on the ACO Provider Portal and incorporated herein by reference.
Grievances and Appeals. The Parties agree to cooperate and upon request to furnish any relevant information to one another, in resolving any Participant's grievance or appeal related to the provision of services.
