Member Inquiries, Grievances & Appeals Sample Clauses

Member Inquiries, Grievances & Appeals. The Contractor shall establish written policies and procedures governing the resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, an appeals process, expedited review procedures and access to the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416. The State will review this information as part of the State’s quality strategy. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, must comply with law, including 42 CFR 438, Subpart F as well as IC 27-13-10 and IC 27-13-
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Member Inquiries, Grievances & Appeals. In compliance with CFR 438.402(c)(1) and 42 CFR 438.408, the Contractor shall allow members to file appeals, grievances, and State fair hearing requests (after receiving notice that an adverse benefit determination is upheld). The Contractor shall allow providers, or authorized representatives, acting on behalf of the member and with the member’s written consent, to request an appeal, file a grievance, or request a State fair hearing request per 42 CFR 438.402(c)(1) and 42 CFR 438.408. The Contractor cannot require providers and/or members to use a specific form to submit an appeal. The Contractor shall have a grievance and appeals system in place in accordance with 42 CFR 438.402(a) and 42 CFR 438.228(a) and establish written policies and procedures governing the process and resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, a single-level appeals process, expedited review procedures and access to external grievance procedure as well as the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416. The State will review this information as part of the State’s quality strategy. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, must comply with law, including 42 CFR 438, Subpart F as well as IC 27-13-10 and IC 27-13-10.1 (if the Contractor is licensed as an HMO) or IC 27-8-28 and IC 27-8-29 (if the Contractor is licensed as an accident and sickness insurer). The term inquiry refers to a concern, issue or question that is expressed orally by a member that will be resolved by the close of the next business day. The term grievance, as defined in 42 CFR 438.400(b), is an expression of dissatisfaction about any matter other than an “adverse benefit determination” as defined below. This may include dissatisfaction related to the quality of care of services rendered or available, aspects of interpersonal relationships such as rudeness of a provider or employee or the failure to respect the member’s rights. A grievance is a complaint about the way a member’s health plan is giving care. For example, a member may file a grievance if the member has a problem calling the plan or if the member is unhappy with the way a staff person at the plan has behaved toward them. A grievance is not the way to deal with a complaint about a treatment decision or a service...
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Member Inquiries, Grievances & Appeals. The Contractor shall establish written policies and procedures governing the resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, an appeals process, expedited review procedures and access to external grievance procedure as well as the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416.
Sample 1Sample 2
Member Inquiries, Grievances & Appeals. The Contractor shall establish written policies and procedures governing the resolution of inquiries, grievances and appeals. At a minimum, the grievance system must include a grievance process, an appeals process, expedited review procedures and access to the State’s fair hearing system. The Contractor shall maintain records of grievances and appeals in accordance with 42 CFR 438.416. The State will review this information as part of the State’s quality strategy. The Contractor’s grievances and appeals system, including the policies for recordkeeping and reporting of grievances and appeals, must comply with law, including 42 CFR 438, Subpart F as well as IC 27-13-10 and IC 27-13-10.1 (if the Contractor is licensed as an HMO) or IC 27-8-28 and IC 27-8-29 (if the Contractor is licensed as an accident and sickness insurer). The term inquiry refers to a concern, issue or question that is expressed orally by a member that will be resolved by the close of the next business day. The term grievance, as defined in 42 CFR 43 8.400(b), is an expression of dissatisfaction about any matter other than an “action” as defined below. This may include dissatisfaction related to the quality of care of services rendered or available, aspects of interpersonal relationships such as rudeness of a provider or employee or the failure to respect the member’s rights. The term appeal is defined as a request for a review of an action. An action, as defined in 42 CFR 438.400(b) is the:  Denial or limited authorization of a requested service, including the type or level of service;  Reduction, suspension or termination of a previously authorized service;  Denial, in whole or in part, of payment for a service;  Failure to provide services in a timely manner, as defined by the State;  Failure of a Contractor to act within the required timeframes; or  For a resident of a rural area with only one Contractor, the denial of a member’s request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network (if applicable). The Contractor must notify the requesting provider, and give the member written notice, of any decision considered an “action” taken by the Contractor, including any decision by the Contractor to deny a service authorization request (a request for the provision of a service by or on behalf of a member), or to authorize a service in an amount, duration or scope that is less than requested. The notice must meet the requirements of 42 ...
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Related to Member Inquiries, Grievances & Appeals

  • 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.

  • Submitting Loop Makeup Service Inquiries 2.9.2.1 C.M. may obtain LMU information by submitting a mechanized LMU query or a Manual LMUSI. Mechanized LMUs should be submitted through BellSouth's OSS interfaces. After obtaining the Loop information from the mechanized LMU process, if C.M. needs further Loop information in order to determine Loop service capability, C.M. may initiate a separate Manual Service Inquiry for a separate nonrecurring charge as set forth in Exhibit A of this Attachment.

  • 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.

  • Grievance Committee The Hospital will recognize a Grievance Committee composed of the Chief Xxxxxxx and not more than (as set out in Local Provisions Appendix) employees selected by the Union who have completed their probationary period. A general representative of the Union may be present at any meeting of the Committee. The purpose of the Committee is to deal with complaints or grievances as set out in this Collective Agreement. The Union shall keep the Hospital notified in writing of the names of the members of the Grievance Committee appointed or selected under this Article as well as the effective date of their respective appointments. A Committee member shall suffer no loss of earnings for time spent during their regular scheduled working hours in attending grievance meetings with the Hospital up to, but not including arbitration. The number of employees on the Grievance Committee shall be determined locally.

  • Informal Grievance Procedure It shall be the mutual responsibility of employees and management to endeavor to resolve grievances informally at the lowest practicable level of management. To this end, the grievant shall first present the grievance to the grievant's immediate supervisor in an informal meeting within ten (10) days after the occurrence of the circumstances giving rise to the grievance or when the grievant first actually knew, or could have reasonably known of them. The grievant may request the meeting be held at any reasonable time, and the supervisor shall meet with the grievant as soon as reasonably practicable after receipt of the request. In the meeting, the grievant and the supervisor shall review the grievance. The employee shall fully and fairly explain: the alleged action or inaction by the employee's department which caused grievance; the written departmental policy allegedly violated by the department; and the remedy the grievant believes will resolve the grievance. The parties shall cooperate in seeking a resolution of the grievance. If questions beyond the scope of the supervisor's authority or knowledge are involved, the supervisor may consult the supervisor's superiors or other County officers. The supervisor shall present an informal, oral decision with supporting reasons to the grievant within ten (10) days after the meeting.

  • 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.

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