Provider Complaint System Sample Clauses
Provider Complaint System. 4.9.7.1 The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor's policies, procedures, or any aspect of a Contractor's administrative functions.
4.9.7.2 The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval quarterly and annually and as updated thereafter.
4.9.7.3 The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor's Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.
4.9.7.4 The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
4.9.7.5 As a part of the Provider Complaint System, the Contractor shall:
4.9.7.5.1 Allow Providers thirty (30) Calendar Days to file a written complaint;
4.9.7.5.2 Allow providers to consolidate complaints or appeals of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint or appeal. Revised 5/19/2008
4.9.7.5.3 Allow a provider that has exhausted the care management organization's internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal the option either to pursue the administrative review process described in subsection (e) of Code Section 49-4-153(e) or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the care management organization and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conduc...
Provider Complaint System a. The Health Plan shall establish and maintain a provider complaint system that permits a provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed actions and claims.
b. The Health Plan shall include its provider complaint system policies and procedures in its provider handbook as described above.
c. The Health Plan shall also distribute the provider complaint system policies and procedures, including claims issues, to out-of-network providers upon request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s website. This summary shall also detail how the provider can request a hard copy from the Health Plan at no charge.
d. As a part of the provider complaint system, the Health Plan shall:
(1) Have dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider complaint and resolve problems;
(2) Identify a staff person specifically designated to receive and process provider complaints;
(3) Allow providers forty-five (45) calendar days to file a written complaint for issues that are not about claims; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
(4) Thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Health Plan’s written policies and procedures; and
(5) Ensure that Health Plan executives with the authority to require corrective action are involved in the provider complaint process.
e. The Health Plan shall provide a written notice of the outcome of the review to the provider.
Provider Complaint System a. The Health Plan shall establish a Provider complaint system that permits a Provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed Actions.
b. The Health Plan shall submit its Provider complaint system policies and procedures to the Agency for written approval.
c. The Health Plan shall include its Provider complaint system policies and procedures in its Provider handbook as described above.
d. The Health Plan shall also distribute the Provider complaint system policies and procedures to out of network providers upon written or oral request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s Web site. This summary shall also detail how the provider can request a hard-copy from the Health Plan at no charge to the provider.
e. As a part of the Provider complaint system, the Health Plan shall:
(1) Allow providers forty-five (45) Calendar Days to file a written complaint;
(2) Have dedicated staff for providers to contact via telephone, electronic mail, or in person, to ask questions, file a provider complaint and resolve problems;
(3) Identify a staff person specifically designated to receive and process provider complaints;
(4) Thoroughly investigate each provider complaint using applicable statutory, regulatory, Contractual and Provider contract provisions, collecting all pertinent facts from all parties and applying the Health Plan’s written policies and procedures; and
(5) Ensure that Health Plan executives with the authority to require corrective action are involved in the provider complaint process.
f. In the event the outcome of the review of the provider complaint is adverse to the provider, the Health Plan shall provide a written notice of adverse action to the provider.
g. The Health Plan shall ensure that claims are processed and comply with the federal and State requirements set forth in 42 CFR 447.45 and 447.46 and Chapter 641, F.S., whichever is more stringent.
Provider Complaint System. 2.18.8.1 The CONTRACTOR shall establish and maintain a provider complaint system for any provider (contract or non-contract) who is not satisfied with the CONTRACTOR’s policies and procedures or a decision made by the contractor that does not impact the provision of services to members.
2.18.8.2 The procedures for resolution of any disputes regarding the payment of claims shall comply with TCA 56-32-226(b).
Provider Complaint System a. The Health Plan shall establish a Provider complaint system that permits a Provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed Actions.
b. The Health Plan shall submit its Provider complaint system policies and procedures to the Agency for written approval.
c. The Health Plan shall include its Provider complaint system policies and procedures in its Provider handbook as described above.
d. The Health Plan shall also distribute the Provider complaint system policies and procedures to out of network providers upon written or oral request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s Web site. This summary shall also detail how the provider can request a hard-copy from the Health Plan at no charge to the provider.
e. As a part of the Provider complaint system, the Health Plan shall:
(1) Allow providers forty-five (45) Calendar Days to file a written complaint;
(2) Have dedicated staff for providers to contact via telephone, electronic mail, or in person, to ask questions, file a provider complaint and resolve problems;
Provider Complaint System. The Health Plan shall establish a Provider complaint system that permits a Provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed Actions.
Provider Complaint System a. The Health Plan shall establish and maintain a provider complaint system that permits a provider to dispute the Health Plan’s policies, procedures, or any aspect of a Health Plan’s administrative functions, including proposed actions and claims.
b. The Health Plan shall include its provider complaint system policies and procedures in its provider handbook as described above.
c. The Health Plan shall also distribute the provider complaint system policies and procedures, including claims issues, to out-of-network providers upon request. The Health Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Health Plan’s website. This summary shall also detail how the provider can request a hard copy from the Health Plan at no charge.
d. As a part of the provider complaint system, the Health Plan shall:
(1) Have dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider complaint and resolve problems;
(2) Identify a staff person specifically designated to receive and process provider complaints;
(3) Allow providers forty-five (45) calendar days to file a written complaint for issues that are not about claims;
(4) Thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Health Plan’s written policies and procedures; and
(5) Ensure that Health Plan executives with the authority to require corrective action are involved in the provider complaint process.
e. The Health Plan shall provide a written notice of the outcome of the review to the provider. WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract The Health Plan shall ensure maintenance of medical records for each enrollee in accordance with this section and with 42 CFR 456. Medical records shall include the quality, quantity, appropriateness, and timeliness of services performed under this Contract.
1. The Health Plan shall follow the medical record standards set forth below for each enrollee's medical records, as appropriate:
a. Include the enrollee’s identifying information, including name, enrollee identification number, date of birth, sex and legal guardianship (if any);
b. Each record shall be legible and maintained in detail;
c. I...