Contractor Grievance and Appeals Policies Sample Clauses

Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals shall include provisions which address the following:  The Contractor shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102, which relates to provider-enrollee communications. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal;  The Contractor shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member;  Throughout the appeals process, the Contractor shall consider the member, representative or estate representative of a deceased member as parties to the appeal;  In accordance with 42 CFR 438.406, provide the member and member representative an opportunity, before and during the appeals process, to examine the member’s case file, including medical records, and any other documents and records considered during the appeals process;  Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing;  Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative the appeal decision. The Contractor’s appeal decision notice shall describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e), which enumerates required content of a notice of resolution;  The Contractor shall notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is licensed as an accident and sickness insurer);  The Contractor shall provide members any reasonable assistance in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;  The Contractor shall ensure that the individual rendering the decision on grievances and appeals were not involved in previous levels of review or decision-making and are health care professionals with appropriate clinical expertise in treating the member’s condition or disease if the decision will be in regard to any of the following: (i) an appea...
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Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following: ▪ The Contractor must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal. ▪ The Contractor must not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member. ▪ Throughout the appeals process, the Contractor must consider the member, representative or estate representative of a deceased member as parties to the appeal per 42 CFR 438.406(b)(6). ▪ In accordance with 42 CFR 438.406(b)(5), provide the member and his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or records considered during the appeals process. ▪ Xxxxx the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing per 42 CFR 438.404(b)(4). ▪ Inform the member and member representative of the limited time available to present evidence and allegations of fact or law, in the case of expedited appeal resolution per 42 CFR 438.406(b)(4) and 42 CFR 438.408(b). ▪ Upon determination of the appeal, ensure there is no delay in notification or mailing to the member and member representative of the appeal decision. The Contractor’s appeal decision notice must describe the actions taken, the reasons for the action, the member’s right to request a State fair hearing, process for filing a fair hearing and other information set forth in 42 CFR 438.408(e). ▪ The Contractor must acknowledge receipt of each grievance and appeal in accordance with 42 CFR 438.406(b)(1) and 42 CFR 438.228(a). ▪ The Contractor must ensure that decision makers take into account all comments EXHIBIT 1.C SCOPE OF WORK documents, records, and other information submitted by the enrollee or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination per 42 CFR 438.406(b)(2)(iii) and 42 CFR 438.228(a). ▪ The Contractor must notify members of the disposition of grievances and appeals pursuant to IC 27-13-10-7 (if the Contractor is licensed as an HMO) or IC 27-8-28-16 (if the Contractor is lic...
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Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following: • The Contractor must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal. • The Contractor must not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member. • Throughout the appeals process, the Contractor must consider the member, representative or estate representative of a deceased member as parties to the appeal. • In accordance with 42 CFR 438.406, provide the member and his representative opportunity, before and during the appeals process, to examine the member’s case file, including medical records and any other documents or records considered during the appeals process. • Allow the member and member representative to present evidence, and allegations of fact or law, in person as well as in writing.
Sample 1
Contractor Grievance and Appeals Policies. The Contractor’s policies and procedures governing grievances and appeals must include provisions which address the following: • The Contractor must not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member, in accordance with 42 CFR 438.102. A provider, acting on behalf of the member and with the member’s written consent, may file an appeal. • The Contractor must not take punitive action against a provider who requests or
Sample 1

Related to Contractor Grievance and Appeals Policies

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

  • Policy Grievances Where either party to this agreement disputes the general application, interpretation or alleged violation of an article of this agreement, the dispute shall be discussed initially with the General Manager, their designate or the Union within 30 calendar days of the occurrence. Where no satisfactory agreement is reached, either party, within a further 14 calendar days, may submit the dispute to arbitration, as set out in Article 9 of this agreement.

  • Policy Grievance Where either Party disputes the general application, interpretation or alleged violation of an article of this Agreement, the dispute shall be discussed initially with the Employer or the Union, as the case may be, within thirty (30) days of the occurrence. Where no satisfactory agreement is reached, either Party may submit the dispute to arbitration, as set out in Article 10.

  • COMPLAINT AND GRIEVANCE PROCEDURE 1. When a member has any grievance or complaint, he shall forthwith convey to his immediate superior, orally or in writing, all facts relative to the grievance and/or complaint. The member and the superior shall make every attempt to resolve the problem at this preliminary stage.

  • COMPLAINTS AND APPEALS As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. WHEN YOU HAVE IDEAS We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. WHEN YOU HAVE QUESTIONS Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

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