Notice of Adverse Benefit Determination. The CONTRACTOR must notify the requesting Provider, and give the Member written notice of any decision by the CONTRACTOR to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements set forth in 42 C.F.R. part 438, subpart F and the Managed Care Policy Manual. The CONTRACTOR must ensure that the Notice of Adverse Benefit Determination clearly explains the reason for the CONTRACTOR’s decision in plain language and provides sufficient detail to allow the Member to make an informed decision regarding appealing the determination. If the reason for the Adverse Benefit Determination is the lack of necessary information, the written notice must clearly explain what information is needed and how and when to provide the necessary information. The CONTRACTOR shall notify the requesting Provider and provide the Member or authorized representative and the Caregiver a notice of Adverse Benefit Determination when a team involved in the individualized planning process recommends a service for a CISC be reduced, modified, delayed, denied, or not approved within ten (10) Calendar Days of recommendation. The notice of Adverse Benefit Determination shall be provided to the Member and the Member’s Caregiver, authorized representative, and legal custodian. CYFD will be the authorized representative for these children. For children fourteen (14) years and older, notices will go the Member, Member’s Caregiver, authorized representative, and legal custodian. The Member’s authorized representative, Caregiver, and legal custodian will be identified by the child with their PPW. Self-Directed Community Benefit (SDCB)
Appears in 4 contracts
Samples: Managed Care Services Agreement, Services Agreement, Managed Care Services Agreement
