Common use of Appeal Procedure Clause in Contracts

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest.

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest.

Appeal Procedure. The definition of an appeal is an action taken by you with respect to your disagreement with our non-coverage of or non-payment for a serviceservice including denial, denialsreductions, reductions or termination terminations of services, denial of enrollment, or your involuntary disenrollment from the program. Information on the appeal process will be provided to you in writing when you enroll and at least annually thereafter. You will also be notified in writing if your LIFE Provider: • will Will not cover or pay for a service that you are requesting. • deniesDenies, reduces, or terminates a serviceservice you already receive. • is Is denying you enrollment into LIFE. • is initiating an involuntary disenrollment Is involuntarily disenrolling you from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. What you appeal determines where your appeal will be heard. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with If you believe that your care plan or conditions of participationlife, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to payhealth, or being out of ability to regain or maintain maximum function would be seriously jeopardized if you do not receive the service area for more than 30 calendar days without prior approved arrangementsin question, will automatically be considered you can request that your LIFE Provider speed up the appeal process. This is called an expedited appeal. If you appeal: • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of under the notice to you. following conditions: o If your Your LIFE Provider is proposing to terminate or reduce services that you are currently receiving, and you have requested the continuation; and o If you You agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you You will be notified in writing of the date when and time of that review to where your appeal will be heard. • You will have an opportunity to present evidence related to your disputedispute in person, as well as in writing. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe response describing the appeal, actions taken, and the outcome of the reviewappeal. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right awayas quickly as your health condition requires. • If the decision is not fully in your favor, a copy of the written report from the independent review entity response will be forwarded immediately to CMS and the Department. You will also be notified in writing of your any additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interesthave.

Appeal Procedure. The definition of an An appeal is an action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your can take when Saint ▇▇▇▇▇▇▇ LIFE Provider: • will not cover or pay for a service or reduces or denies a service request. At the time of enrollment and at least annually thereafter Saint ▇▇▇▇▇▇▇ LIFE will tell you, your caregiver, or authorized representative about the appeals process and provide you with the information in writing. If you, your caregiver, or designated representative request to start, continue or modify a certain service, your request will be brought to the team as quickly as possible, but no later than three (3) calendar days from the time the request is made. The Saint ▇▇▇▇▇▇▇ LIFE team will look at the request to evaluate if the services is necessary to meet the participant’s medical, physical, emotional, and social needs. A member of the team will notify you or your designated representative of their decision to approve, deny or partially deny the requested service as quickly as your condition requires, but no later than three (3) calendar days from the time the request is brought to the team. The member will explain why the requested service is not a necessary service to improve or maintain your overall health status and tell you that you are requesting. • denies, reduces, or terminates have a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how right to appeal the decision if you do not agree with the decision. You must request an will also receive a letter from ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE with the explanation in writing and receive a copy of your appeal within rights. All appeals will remain private. You or your designated representative have 30 calendar days of from the date you receive the notice was sent denial letter from ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE to request an appeal. Should you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of your designated representative choose to appeal the service area for more denied or partially denied service, please contact your Social Worker. Your Social Worker will tell you how the appeals process works and can help you file your appeal if you so desire. ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will respond to and make a decision to resolve your appeal as quickly as your health condition requires, but no later than 30 calendar days without prior approved arrangementsafter we receive your request to appeal. Everyone who has an interest in the appeal, including you, will automatically be considered an appealhave a chance to give facts about the appeal in person, and/or in writing. • Confirmation of receipt of your request for Your appeal will be sent to you within 24 hours of receipt reviewed by an individual who was not involved in the original service request decision. This individual is a well-qualified professional and impartial third party, who does not have a stake in the result of your requestappeal. • Your You or your representative may give facts about your appeal to this individual in writing, over the phone, or in person. During the appeals process if you are enrolled in Medicaid, Saint ▇▇▇▇▇▇▇ LIFE Provider will continue to furnish disputed provide services until a final determination decision is made if you appeal within 30 calendar days of under the notice following conditions: • If Saint ▇▇▇▇▇▇▇ LIFE wants to you. o If your LIFE Provider is proposing to terminate end or reduce services being given, you may request that those services continue during the appeal process. • If you choose to continue the services, you may be have to pay for those service if the appeal is not decided in your favor. Saint ▇▇▇▇▇▇▇ LIFE will continue to provide all other services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your lifelife or health is in danger without the denied or partially denied service, health, or ability ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will respond to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal processas quickly as your health calls for or within seventy- two (72) hours after ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE receives your request to appeal. This is called an expedited appeal. You will receive the outcome of the This expedited appeal within 72 hours of receipt of your appeal. may be increased to fourteen (14) days if you ask for more time or if ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies can explain to the Department there State Administering Agency (SAA) more time is a need needed for additional information and how it would be in the delay participant’s best interest. If the appeal decision is made in your interestfavor, ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will notify you and provide the requested service as quickly as your health requires. If the decision of the Impartial third party is not made in your favor, ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will notify you, the Center for Medicare and Medicaid Services, and the State Administering Agency (SAA) in writing. If you choose, you may also file an appeal under Medicare or Medicaid. ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will help you or your representative to file this appeal to Medicare, or Medicaid or both. The process you choose depends upon whether you are eligible for Medicare, Medicaid, OR eligible for both Medicaid and Medicare. If you are enrolled in both Medicare and Medicaid OR Medicaid only, you or your designated representative have the right to request a State Fair Hearing by contacting: If you are enrolled in both Medicare and Medicaid OR Medicare only, you or your designated representative may use Medicare’s external appeal process. Your Saint ▇▇▇▇▇▇▇ LIFE Social Worker will assist you with your appeal. As a participant in LIFE you have the following rights: You have the right to be treated with dignity and respect at all times, to have all of your care kept private and to get compassionate, considerate care. • Get all of your health care in a safe, clean environment in an accessible manner. • Be free from harm. This includes receiving excessive medicines; Physical or Mental abuse or neglect; Physical punishment; being placed alone against your will; or have any physical or chemical restraint used on you for discipline or convenience of staff. This is not medicine that you need to treat your health conditions or to prevent injury. • Use your rights in the Saint ▇▇▇▇▇▇▇ LIFE program. • Get help, if you need it, to use the Medicare and Medicaid complaint and appeal processes, as well as your civil and other legal rights. • Be encouraged and helped in talking to ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE staff about changes in policy and services you think should be made. • Use a telephone while at the Saint ▇▇▇▇▇▇▇ LIFE Center. • Not to have to do work or services for the Saint ▇▇▇▇▇▇▇ LIFE program. • Each participant has the right to considerate respectful care from all Saint ▇▇▇▇▇▇▇ LIFE staff members and contractors at all times. • Each participant has the right not to be discriminated against in the delivery of required PACE services based on: Race / Ethnic Origin, Religion, Age, Sex, Mental or physical ability, Sexual Orientation, or Source of payment for your health care (For example, Medicare or Medicaid). • Discrimination is against the law. Every company or agency that works with Medicare and Medicaid must obey the law. • If you think you have been discriminated against for any of these reasons, inform a ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE staff member to assist you with your concern. • If you have any questions, you can call the Office for Civil Rights at Toll free: ▇-▇▇▇-▇▇▇-▇▇▇▇. TTD/TTY users should call ▇-▇▇▇-▇▇▇-▇▇▇▇.

Appeal Procedure. The definition of an appeal If the claimant’s claim is action taken by you with respect denied, the claimant (or his or her authorized representative) may apply in writing to your disagreement with our non-coverage of or non-payment the Administrator for a servicereview of the decision denying the claim. Review must be requested within 60 days following the date the claimant received the written notice of their claim denial or else the claimant loses the right to review. The claimant (or representative) then has the right to review and obtain copies of all documents and other information relevant to the claim, denialsupon request and at no charge, reductions and to submit issues and comments in writing. The Administrator will provide written notice of the decision on review within 60 days after it receives a review request. If additional time (up to 60 days) is needed to review the request, the claimant (or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You representative) will be notified given written notice of the reason for the delay. This notice of extension will indicate the special circumstances requiring the extension of time and the date by which the Administrator expects to render its decision. If the claim is denied (in writing if your LIFE Provider: • full or in part), the claimant will not cover or pay be provided a written notice explaining the specific reasons for a service that you are requesting. • denies, reduces, or terminates a service. • the denial and referring to the provisions of the Policy on which the denial is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFEbased. The notice shall also include a statement that the claimant will instruct you on how be provided, upon request and free of charge, reasonable access to, and copies of, all documents and other information relevant to appeal the decision if you do not agree claim and a statement regarding the claimant’s right to bring an action under Section 502(a) of ERISA. Plan Name: FireEye, Inc. Change of Control Severance Policy for Officers Plan Sponsor: FireEye, Inc. ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, Milpitas, CA, 95035 Identification Number: 550 Plan Year: Company’s Fiscal Year Plan Administrator: FireEye, Inc. Attention: Administrator of the FireEye, Inc. Change of Control Severance Policy for Officers ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ Milpitas, CA 95035 Legal Process: FireEye, Inc. Attention: General Counsel ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ Milpitas, CA 95035 Service of process may also be made upon the Plan Administrator. Type of Plan: Severance Plan/Employee Welfare Benefit Plan Plan Costs: The cost of the Policy is paid by the Company. Policy Eligible Employees have certain rights and protections under ERISA: They may examine (without charge) all Policy documents, including any amendments and copies of all documents filed with the decisionU.S. Department of Labor, such as the Policy’s annual report (Internal Revenue Service Form 5500). You must These documents are available for review in the Company’s Human Resources Department. They may obtain copies of all Policy documents and other Policy information upon written request an appeal within 30 calendar days to the Plan Administrator. A reasonable charge may be made for such copies. In addition to creating rights for Eligible Employees, ▇▇▇▇▇ imposes duties upon the people who are responsible for the operation of the date Policy. The people who operate the notice was sent Policy (called “fiduciaries”) have a duty to youdo so prudently and in the interests of Eligible Employees. An involuntary disenrollment No one, including the Company or any other person, may fire or otherwise discriminate against an Eligible Employee in any way to prevent them from obtaining a benefit under the Policy or exercising rights under ERISA. If an Eligible Employee’s claim for non-compliance with your care plan a severance benefit is denied, in whole or conditions of participationin part, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will they must receive a written report explanation of the independent reason for the denial. An Eligible Employee has the right to have the denial of their claim reviewed. (The claim review entity’s review procedure is explained above.) Under ERISA, there are steps Eligible Employees can take to enforce the above rights. For instance, if an Eligible Employee requests materials and does not receive them within 30 calendar days days, they may file suit in a federal court. In such a case, the court may require the Administrator to provide the materials and to pay the Eligible Employee up to $110 a day until they receive the materials, unless the materials were not sent because of receipt of your appeal. That report will describe reasons beyond the appeal, actions taken, and outcome control of the reviewPlan Administrator. • If your appeal an Eligible Employee has a claim which is resolved denied or ignored, in your favorwhole or in part, your LIFE Provider he or she may file suit in a state or federal court. If it should happen that an Eligible Employee is discriminated against for asserting their rights, he or she may seek assistance from the U.S. Department of Labor, or may file suit in a federal court. In any case, the court will provide or decide who will pay for the disputed service right awaycourt costs and legal fees. • If the decision Eligible Employee is not in your favorsuccessful, a copy the court may order the person sued to pay these costs and fees. If the Eligible Employee loses, the court may order the Eligible Employee to pay these costs and fees, for example, if it finds that the claim is frivolous. If an Eligible Employee has any questions regarding the Policy, please contact the Plan Administrator. If an Eligible Employee has any questions about this statement or about their rights under ERISA, they may contact the nearest area office of the written report from Employee Benefits Security Administration (formerly the independent review entity will be forwarded immediately to CMS Pension and Welfare Benefits Administration), U.S. Department of Labor, listed in the Department. You will also be notified in writing of your additional appeal rights under Medicaretelephone directory, or Medical the Division of Technical Assistance through and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇. Washington, D.C. 20210. An Eligible Employee may also obtain certain publications about their rights and responsibilities under ERISA by calling the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome publications hotline of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interestEmployee Benefits Security Administration.

Appeal Procedure. If a claim is denied, the claimant may write to the Plan Administrator (or to the joint board in cases of claims for disability benefits) for a review of the claim on appeal. The definition of claimant must request the review on appeal within 60 days after the claim is denied. In cases involving disability, however, the period to file an appeal is action taken by you with respect extended to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar 180 days of after the date the claim is denied. A claimant who fails to submit an appeal request within the 60 or 180 day period (as applicable) will have no further right to appeal. As part of the appeal review procedure, the claimant will be allowed to: • submit additional documents, records, and information relating to the claim; • request access to and receive copies (free of charge) of all plan documents, records, and other information affecting the claim; • appeal the denial in writing; and • have someone act as the claimant’s representative in the appeal procedure. The Plan Administrator’s or joint board’s review of a claim on appeal will take into account all comments, documents, records, and other information relating to the claim submitted by the claimant, without regard to whether such information was submitted or considered in the initial claim determination. Within 60 days (or 120 days in some cases) after you file your request, the Plan Administrator will notify you of the final decision. If the Plan Administrator denies the claim on appeal (in whole or in part), it will provide the claimant with a notice was sent that advises the claimant of the type of information included in the initial notice of claim denial and the right to you. An involuntary disenrollment for non-compliance with your care plan or conditions receive (upon request and free of participationcharge) copies of all documents, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to payrecords, or being out other information that were submitted to the plan, considered by the plan, or generated in the course of making the service area benefit determination. For claims involving disability determinations, the appeal review period is reduced to 45 days (the review period can be extended for more than 30 calendar up to another 45 days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of with advance written notice) after the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if date the appeal is not resolved in your favorfiled. • An independent The review entity will review your of any appeal and you that involves disability determinations based on a medical judgment will be notified performed, without deference to the initial determination, by consulting with a qualified health care professional who: (a) has appropriate experience in writing the field of medicine involved; and (b) was neither consulted in connection with the initial denial nor a subordinate of any such individual. When ruling upon both the initial claims and Appeals, the Plan Administrator and the joint board shall have full discretionary authority to determine all questions arising in the administration, interpretation and application of the date Plan. A decision on review shall be final and time of that binding. If a claimant fails to file a request for review according to the Plan’s claim procedures, the claimant shall have an opportunity no rights to present evidence related review and no right to your dispute. • You will receive a written report bring action in any court, and the denial of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, claim shall be final and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interestbinding.

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Providerwe: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is ; are denying enrollment into LIFE. • is ; or are initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the our decision if you do not agree with the decisionit. You must request an appeal within 30 calendar days of the date the our notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider We will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the our notice to you. o If your LIFE Provider is ; if we are proposing to terminate or reduce services that you are currently receiving; and o If if you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity impartial party will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s third party review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider we will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent third party review entity will be forwarded immediately to CMS the federal government, the Pennsylvania Department of Human Services and the DepartmentLocal Area Agency on Aging. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider We will assist you with your appealin choosing which to pursue and forward the appeal to the appropriate entity. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider we speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest.