Common use of Resolution and Notification Clause in Contracts

Resolution and Notification. 1. The Health Plan shall follow Agency guidelines in resolving grievances and appeals as expeditiously as possible, observing required timeframes and taking into account the enrollee’s health condition. 2. A grievance shall be reviewed and notice of results sent to the enrollee no later than ninety (90) calendar days from the date the Health Plan receives it. 3. An appeal shall be heard and notice of results sent to the enrollee no later than forty-five (45) calendar days from the date the Health Plan receives it. 4. The timeframe for a grievance or appeal may be extended up to fourteen (14) calendar days if: a. The enrollee asks for an extension, or the Health Plan documents that additional information is needed and the delay is in the enrollee’s interest; b. If the timeframe is extended other than at the enrollee’s request, the Health Plan shall notify the enrollee within five (5) business days of the determination, in writing, of the reason for the delay. 5. The Health Plan shall complete the grievance process in time to accommodate an enrollee’s disenrollment effective date, which can be no later than the first day of the second month after the filing of a request for disenrollment. 6. The Health Plan shall provide written notice of disposition of an appeal. In the case of an expedited appeal denial, the Health Plan also shall provide oral notice by close of business on the day of disposition, and written notice within two (2) calendar days after the disposition in accordance with 42 CFR 438.410(c).