Expedited Resolution of Appeals. An expedited review by the Contractor of an Adverse Benefit Determination. The Contractor shall establish and maintain an expedited review process for Appeals when the Contractor determines that allowing the time for a standard resolution could seriously jeopardize the Member’s life, health, or ability to attain, maintain, or regain maximum function. Such a determination is based on:
Expedited Resolution of Appeals. Contractor must establish and maintain an expedited review process for appeals, when Contractor determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. The contractor must inform the member of the limited time available for the member to present evidence and allegations of fact or law, in person and in writing, in the case of an expedited resolution. Contractor must resolve a request for expedited appeal and notify affected parties of the resolution within three (3) working days after Contractor receives the request. Contractor may extend the timeframe by up to fourteen (14) calendar days, if the member requests the extension, or Contractor can show (to the satisfaction of the State, upon the State’s request) that there is need for additional information and how the delay is in the member’s interest. Contractor must ensure that punitive action is not taken against a provider who requests an expedited resolution or who supports a member’s request. If Contractor denies a request for expedited resolution of an appeal, it must transfer the appeal to the timeframe for standard resolution in accordance with Rhode Island Medicaid Managed Care Grievance and Appeals Process and make reasonable efforts to give the member prompt oral notice of the denial, and follow up within two (2) calendar days with written notice. Should any of the above timeframes conflict with State regulations under R23-17.12-1-UR, Contractor agrees that the most stringent timeframes shall apply.
Expedited Resolution of Appeals. The contractor shall establish and maintain an expedited review process for appeals when the contractor determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee’s behalf or supporting the enrollee’s request) that taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or Exhibit 10.6.9 ability to attain, maintain or regain maximum function. Exhibit 10.6.9 C. The contractor hereby agrees to medical audits in accordance with the protocols for care specified in this contract, in accordance with medical community standards for care, and of the quality of car provided all enrollees, as may be required by appropriate regulatory agencies. D. The contractor shall cooperate with DMAHS in carrying out the provisions of applicable statutes, regulations, and guidelines affecting the administration of this contract. E. The contractor shall distribute to all subcontractors providing services to enrollees, informational materials approved by DMAHS that outlines the nature, scope, and requirements of this contract. F. The contractor, with the prior written approval of DMAHS, shall print and distribute reporting forms and instructions, as necessary whenever such forms are required by this contract.