Common use of Appeal Procedure Clause in Contracts

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest. General Provisions

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE General Provisions CHANGES TO AGREEMENT: Changes to this agreement may extend the 72-hour timeframe be made if they are approved by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interestCMS. General ProvisionsYour LIFE Provider will give you at least 30 days written notice of any change.

Appeal Procedure. The definition of an appeal is an action taken by you with respect to your disagreement with our non-coverage of or non-payment for a serviceservice including denial, denialsreductions, reductions or termination terminations of services, denial of enrollment, or your involuntary disenrollment from the program. Information on the appeal process will be provided to you in writing when you enroll and at least annually thereafter. You will also be notified in writing if your LIFE Provider: • will Will not cover or pay for a service that you are requesting. • deniesDenies, reduces, or terminates a serviceservice you already receive. • is Is denying you enrollment into LIFE. • is initiating an involuntary disenrollment Is involuntarily disenrolling you from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. What you appeal determines where your appeal will be heard. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for nonNote: Involuntary disenrollments from your LIFE Program result in an automatic appeal, which will be heard as an impartial third-compliance with party review. If you believe that your care plan or conditions of participationlife, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to payhealth, or being out of ability to regain or maintain maximum function would be seriously jeopardized if you do not receive the service area for more than 30 calendar days without prior approved arrangementsin question, will automatically be considered you can request that your LIFE Provider speed up the appeal process. This is called an expedited appeal. If you appeal: • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of under the notice to you. following conditions: o If your Your LIFE Provider is proposing to terminate or reduce services that you are currently receiving, and you have requested the continuation; and o If you You agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you You will be notified in writing of the date when and time of that review to where your appeal will be heard. • You will have an opportunity to present evidence related to your disputedispute in person, as well as in writing. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe response describing the appeal, actions taken, and the outcome of the reviewappeal. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right awayas quickly as your health condition requires. • If the decision is not fully in your favor, a copy of the written report from the independent review entity response will be forwarded immediately to CMS and the Department. You will also be notified in writing of your any additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interesthave. General Provisions

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Provider: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the decision if you do not agree with the decision. You must request an appeal within 30 calendar days of the date the notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the notice to you. o If your LIFE Provider is proposing to terminate or reduce services that you are currently receiving; and o If you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent review entity will be forwarded immediately to CMS and the Department. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider will assist you with your appeal. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest. General Provisions.

Appeal Procedure. The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denials, reductions or termination of services, denial of enrollment, or your involuntary disenrollment from the program. You will be notified in writing if your LIFE Providerwe: • will not cover or pay for a service that you are receiving or requesting. • denies, reduces, or terminates a service. • is ; are denying enrollment into LIFE. • is ; or are initiating an involuntary disenrollment from LIFE. The notice will instruct you on how to appeal the our decision if you do not agree with the decisionit. You must request an appeal within 30 calendar days of the date the our notice was sent to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 calendar days without prior approved arrangements, will automatically be considered an appeal. • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request. • Your LIFE Provider We will continue to furnish disputed services until a final determination is made if you appeal within 30 calendar days of the our notice to you. o If your LIFE Provider is ; if we are proposing to terminate or reduce services that you are currently receiving; and o If if you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor. • An independent review entity impartial party will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute. • You will receive a written report of the independent review entity’s third party review within 30 calendar days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review. • If your appeal is resolved in your favor, your LIFE Provider we will provide or pay for the disputed service right away. • If the decision is not in your favor, a copy of the written report from the independent third party review entity will be forwarded immediately to CMS the federal government, the Pennsylvania Department of Human Services and the DepartmentLocal Area Agency on Aging. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. Your LIFE Provider We will assist you with your appealin choosing which to pursue and forward the appeal to the appropriate entity. • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that your LIFE Provider we speed up the appeal process. This is called an expedited appeal. You In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal. LIFE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: You request the extension or LIFE justifies to the Department there is a need for additional information and how the delay is in your interest. General Provisions.