Adverse Benefit Determination Due to Failure to Resolve Appeals and Grievances within Prescribed Timeframes Sample Clauses

Adverse Benefit Determination Due to Failure to Resolve Appeals and Grievances within Prescribed Timeframes. (A) Failure of the Contractor to act within the prescribed timeframes provided for resolving and giving resolution notice for Appeals and Grievances constitutes an Adverse Benefit Determination. The Contractor shall provide a Notice of Adverse Benefit Determination to the Aggrieved Person at the time the Contractor determines the timeframe for resolving the Appeal or Grievance will not be met. (B) If the Contractor does not resolve an Appeal within the required timeframe, the Aggrieved Person shall be considered as having completed the Contractor’s Appeal process. The Contractor’s failure to provide resolution of the Appeal within the required timeframe is an Adverse Benefit Determination and the Aggrieved Person is allowed to file a request for a State Fair Hearing as the Aggrieved Person has already exhausted the Contractor’s internal Appeals process. The Contractor may not require the Aggrieved Person to go through the Contractor’s internal Appeals process again. (C) When issuing a Notice of Adverse Benefit Determination due to failure to resolve an Appeal within the required timeframe, the Contractor shall include in the Notice of Adverse Benefit Determination information regarding the procedures and timeframes for filing a request for a State Fair Hearing rather than information on filing an Appeal request. The Contractor shall also attach to the Notice of Adverse Benefit Determination a copy of the State Fair Hearing request form that the Aggrieved Person can submit to request a State Fair Hearing. (D) If the Enrollee is not the Aggrieved Person, the Contractor shall provide the Notice of Adverse Benefit Determination to the Enrollee as well as to the Aggrieved Person.