Actions, Grievances, Appeals and Independent Reviews Sample Clauses
Actions, Grievances, Appeals and Independent Reviews. The Contractor shall maintain records of all actions, grievances, appeals and independent reviews of adverse appeal decisions by an independent review organization.
10.10.1. The records shall include actions, grievances and appeals handled by delegated entities.
10.10.2. The Contractor shall provide a report of complete actions, grievances, appeals and independent reviews to DSHS biannually for the prior six months.
10.10.2.1. The report for the six months ending March 31st is due no later than June 1st.
10.10.2.2. The report for the six months ending September 30th is due no later than November 1st.
10.10.3. The Contractor is responsible for maintenance of records for and reporting of any grievance, actions and appeals handled by delegated entities.
10.10.4. Delegated actions, grievances and appeals are to be integrated into the Contractor’s report.
10.10.5. Data shall be reported in the DSHS and Contractor agreed upon format.
10.10.6. The report medium shall be specified by DSHS.
10.10.7. Reporting of actions shall include all denials or limited authorization of a requested service, including the type or level of service, and the reduction, suspension, or termination of a previously authorized service but will not include denials of payment to providers unless the enrollee may be liable for payment.
10.10.8. The Contractor shall provide information to DSHS regarding denial of payment to providers upon request.
10.10.9. Reporting of grievances shall include all expressions of enrollee dissatisfaction not related to an action.
10.10.10. The records shall include, at a minimum:
Actions, Grievances, Appeals and Independent Reviews. The Contractor shall maintain records of all actions, grievances, appeals and independent reviews of adverse appeal decisions by an independent review organization.
10.10.1 The records shall include actions, grievances and appeals handled by delegated entities.
10.10.2 The Contractor shall provide a report of complete actions, grievances, appeals and independent reviews to DSHS biannually for the prior six months.
10.10.2.1 The report for the six months ending March 31 is due no later than June 1.
10.10.2.2 The report for the six months ending September 30 is due no later than November 1.
10.10.3 The Contractor is responsible for maintenance of records for and reporting of any grievance, actions and appeals handled by delegated entities.
10.10.4 Delegated actions, grievances and appeals are to be integrated into the Contractor’s report.
10.10.5 Data shall be reported in the DSHS and Contractor agreed upon format.
10.10.6 The report medium shall be specified by DSHS.
Actions, Grievances, Appeals and Independent Reviews. The Contractor shall maintain records of all actions, grievances, appeals and independent reviews.
13.10.1. The records shall include actions, grievances and appeals handled by delegated entities.
13.10.2. The Contractor shall provide a report of complete actions, grievances, appeals and independent reviews to DSHS in accord with the Grievance System Reporting Requirements published by DSHS (see Attachment A for website link).
13.10.3. The Contractor is responsible for maintenance of records for and reporting of any grievance, actions and appeals handled by delegated entities.
13.10.4. Delegated actions, grievances and appeals are to be integrated into the Contractor’s report.
13.10.5. Data shall be reported in the DSHS and Contractor agreed upon format. Reports that do not meet the Grievance System Reporting Requirements shall be returned to the Contractor for correction. Corrected reports will be resubmitted to DSHS within 30 calendar days.
13.10.6. The report medium shall be specified by DSHS and shall be in accord with the Grievance System Reporting Requirements published by DSHS (See Attachment A for website link).
13.10.7. Reporting of actions shall include all denials or limited authorization of a requested service, including the type or level of service, and the reduction, suspension, or termination of a previously authorized service but will not include denials of payment to providers unless the enrollee may be liable for payment in accord with WAC 3▇▇-▇▇▇-▇▇▇▇ and the provisions of this Contract.
13.10.8. The Contractor shall provide information to DSHS regarding denial of payment to providers upon request.
13.10.9. Reporting of grievances shall include all expressions of enrollee dissatisfaction not related to an action. All grievances are to be recorded and counted whether the grievance is remedied by the Contractor immediately or through its grievance and quality of care service procedures.