Provider Complaints. MCOs must develop, implement, and maintain a system for tracking and resolving all Medicaid Provider complaints. Within this process, the MCO must respond fully and completely to each complaint and establish a tracking mechanism to document the status and final disposition of each Provider complaint. The MCO must resolve Provider complaints within 30 days from the date the complaint is received. The HMO is subject to remedies, including liquidated damages, if at least 98 percent of Provider Complaints are not resolved within 30 days of receipt of the Complaint by the HMO. Please see the Attachment A “Uniform Managed Care Contract Terms & Conditions” and Attachment B-3 , “Deliverables/Liquidated Damages Matrix.” MCOs must also resolve Provider complaints received by HHSC and referred to the MCOs no later than the due date indicated on HHSC’s notification form. HHSC will generally provide MCOs ten (10) Business Days to resolve such complaints. If an MCO cannot resolve a complaint by the due date indicated on the notification form, it may submit a request to extend the deadline. HHSC may, in its reasonable discretion, grant a written extension if the MCO demonstrates good cause. Unless HHSC has granted a written extension as described above, the MCO is subject to contractual remedies, including liquidated damages if Provider complaints are not resolved by the timeframes indicated herein.
Provider Complaints. Medicaid HMOs must develop, implement, and maintain a system for tracking and resolving all Medicaid Provider complaints. Within this process, the HMO must respond fully and completely to each complaint and establish a tracking mechanism to document the status and final disposition of each Provider complaint. The HMO must resolve Provider Complaints within 30 days from the date the Complaint is received.
Provider Complaints. The CONTRACTOR shall establish and maintain written policies and procedures for the filing of Provider complaints. A Provider shall have the right to file a complaint with the CONTRACTOR. Provider complaints shall be resolved within thirty (30) Calendar Days. If the Provider complaint is not resolved within thirty (30) Calendar Days, the CONTRACTOR shall request a fourteen (14) Calendar Day extension from the Provider. If the Provider requests the extension, the extension shall be approved by the CONTRACTOR. A Provider shall have the right to file a complaint with the CONTRACTOR regarding provider payment issues, including Claims disputes, and/or Utilization Management decisions. When the CONTRACTOR determines the Claim(s) subject to the Claims dispute were denied/paid incorrectly, the CONTRACTOR must correct the error and reprocess and pay the Claim(s) within thirty (30) calendar days of the notice of resolution. The CONTRACTOR must also automatically reprocess and pay all other Provider Claims affected by the same issue to correctly adjudicate all other Provider Claims similarly situated. Program Integrity
Provider Complaints. Medicaid HMOs must develop, implement, and maintain a system for tracking and resolving all Medicaid Provider complaints. Within this process, the HMO must respond fully and completely to each complaint and establish a tracking mechanism to document the status and final disposition of each Provider complaint. The HMO must resolve Provider Complaints within 30 days from the date the Complaint is received. The HMO is subject to remedies, including liquidated damages, if at least 98 percent of Provider Complaints are not resolved within 30 days of receipt of the Complaint by the HMO. Please see the Uniform Managed Care Contract Terms & Conditions and Attachment B-5, Deliverables/Liquidated Damages Matrix. HMOs must also resolve Provider Complaints received by HHSC no later than the due date indicated on HHSC’s notification form. HHSC will generally provide HMOs ten (10) Business Days to resolve such Complaints. If an HMO cannot resolve a Complaint by the due date indicated on the notification form, it may submit a request to extend the deadline. HHSC may, in its reasonable discretion, grant a written extension if the HMO demonstrates good cause. Unless HHSC has granted a written extension as described above, the HMO is subject to remedies, including liquidated damages if Provider Complaints are not resolved by the timeframes indicated herein.
Provider Complaints. Medicaid HMOs must develop, implement, and maintain a system for tracking and resolving all Medicaid Provider complaints. Within this process, the HMO must respond fully and completely to each complaint and establish a tracking mechanism to document the status and final disposition of each Provider complaint. The HMO must resolve Provider Complaints within 30 days from the date the Complaint is received. HHSC may, in its reasonable discretion, grant a written extension if the HMO demonstrates good cause. HMOs must also resolve Provider Complaints received by HHSC no later than the due date indicated on HHSC’s notification form. HHSC will generally provide HMOs ten (10) Business Days to resolve such Complaints. If an HMO cannot resolve a Complaint by the due date indicated on the notification form, it may submit a request to extend the deadline. HHSC may, in its reasonable discretion, grant a written extension if the HMO demonstrates good cause. Unless HHSC has granted a written extension as described above, the HMO is subject to remedies, including liquidated damages if Provider Complaints are not resolved by the timeframes indicated herein.
Provider Complaints. Physician and Hospital shall work together, in good faith, to investigate any complaints made by Hospital, any patient, other health care provider or personnel concerning any Provider, and Physician shall promptly take definitive steps to resolve the complaint with appropriate action.
Provider Complaints. Provider shall track and report complaints against Provider to Subcontractor and/or Health Plan.
Provider Complaints. 1. To include in its provider complaint process at least the following elements: a. The requirements set forth in COMAR 10.09.71.03B; and
Provider Complaints. The CONTRACTOR shall establish and maintain written policies and procedures for the filing of Provider complaints. A Provider shall have the right to file a complaint with the CONTRACTOR. Provider complaints shall be resolved within thirty (30) Calendar Days. If the Provider complaint is not resolved within thirty (30) Calendar Days, the CONTRACTOR shall request a fourteen (14) Calendar Day extension from the Provider. If the Provider requests the extension, the extension shall be approved by the CONTRACTOR. A Provider shall have the right to file a complaint with the CONTRACTOR regarding provider payment issues, including Claims disputes, and/or Utilization Management decisions. Program Integrity General The CONTRACTOR, must meet Program Integrity requirements in accordance with 42 C.F.R. Part 438 Subpart H and other Program Integrity requirements as set forth in this Section 4.18. Compliance Program In accordance with 42 C.F.R. § 438.608(a)(1), the CONTRACTOR must implement and maintain a compliance program that includes, at a minimum, the following elements: Written policies, procedures, and standards of conduct that demonstrate compliance with requirements and standards under this Agreement and all applicable federal and State requirements; A designated Compliance Officer responsible for developing and implementing policies and procedures designed to ensure compliance with this Agreement and who reports directly to the CEO and the CONTRACTOR’s board of directors; The establishment of a regulatory compliance committee on the Contractor’s board of directors and at the senior management level charged with overseeing the CONTRACTOR’s compliance program and compliance with the requirements under this Agreement; A system for training and education for the CONTRACTOR’S Compliance Officer, senior management, and employees for the federal and State standards and requirements under this Agreement; Effective lines of communication between the Compliance Officer and the CONTRACTOR’s employees; Enforcement of standards through well-publicized disciplinary guidelines; and A system of dedicated staff with established and implemented procedures for routine internal monitoring and auditing of compliance risks, prompt response to compliance issues, investigations of potential compliance problems identified in the course of self-evaluation and audits, prompt and thorough correction of such problems to reduce the potential for recurrence, and ongoing compliance with the r...
