Appeal Levels Sample Clauses

Appeal Levels. 2.14.1.5.1. Initial Appeals (first level internal Appeal) will be filed with the Contractor. 2.14.1.5.2. Subsequent Appeals for traditional Medicare A and B services that are not fully in favor of the Enrollee will be automatically forwarded to the Medicare IRE by the Contractor. 2.14.1.5.3. Subsequent Appeals for services covered by DMAS only (including but not limited to, LTSS, Virginia Medicaid-covered drugs excluded from Medicare Part D, and behavioral health) may be appealed to the DMAS Appeals Division after the initial plan- level Appeal has been completed, within the required timeframe. 2.14.1.5.4. Subsequent Appeals for services for which Medicare and Medicaid overlap (including, but not limited to, home health, durable medical equipment and skilled therapies, but excluding Part D) will be auto-forwarded to the IRE by the Contractor, and an Enrollee may also file a request for a hearing with the DMAS Appeals Division. If an Appeal is filed with both the IRE and the DMAS Appeals Division, any determination in favor of the Enrollee will bind the Contractor and will require payment by the Contractor for the service or item in question granted in the Enrollee’s favor which is closest to the Enrollee’s relief requested on Appeal.

Appeal Levels. Initial appeals must be filed with the CICO. The filing of an internal appeal and exhaustion of the CICO internal Appeal process is a prerequisite to filing an external appeal to Medicare or Medicaid. a. Subsequent Appeals for traditional Medicare A and B services will be automatically forwarded to the Medicare Independent Review Entity (IRE) if the plan upholds its initial denial. b. For Medicaid-only benefits, if the resolution following the CICO Appeal process is not wholly in favor of the Enrollee, such Enrollee or his/her authorized representative may request a State Fair Hearing.