Contractor's Program to Address Complaints Clause Samples

Contractor's Program to Address Complaints a) The Contractor shall establish and maintain a comprehensive program designed to address clinical and other complaints, and appeals of complaint determinations, which may be brought by Enrollees, consistent with Article 44 of the New York State P.H.L and applicable Federal regulations. b) The program must include methods for prompt internal adjudication of Enrollee complaints and appeals and provide for the maintenance of a written record of all complaints and appeals received and reviewed and their disposition. c) The Contractor shall ensure that persons with authority to require corrective action participate in the complaint and appeal process. d) The Contractor must have in place effective mechanisms to ensure consistent application of review criteria for Complaint Determinations about requests for services, including a Complaint about a PCP’s decision to deny a request for a referral, or to deny or reduce a benefit or service, or to authorize a service for less than requested. e) If the Contractor subcontracts for Complaint Determinations, the Contractor must ensure that its subcontractors have in place and follow written policies and procedures for delegated activities regarding the processing of Complaints regarding requests for services, including a Complaint about a PCP’s decision to deny a request for a referral, or to deny or reduce a benefit or service, or to authorize a service for less than requested. f) The Contractor must ensure that compensation to individuals or entities that make Complaint Determinations is not structured to include incentives that would result in the denial of a medically necessary service. g) The Contractor or its subcontractor may not arbitrarily deny or reduce the amount, duration, or scope of a covered service solely because of the diagnosis, type of illness, or Enrollee’s condition.