Action Due to Failure to Resolve Appeals or Grievances Within Prescribed Timeframes Clause Samples

Action Due to Failure to Resolve Appeals or Grievances Within Prescribed Timeframes. (A) Failure of the Contractor to act within the prescribed timeframes provided for resolving and giving resolution notice for Appeals or Grievances constitutes an Action. The Contractor shall provide a Notice of Action to the Enrollee at the time the Contractor determines the time frame for resolving the Appeal or Grievance will not be met. (B) If the Contractor does not resolve an Appeal within the required time frame, the Enrollee shall be considered as having completed the Contractor’s Appeal process. The Contractor’s failure to provide resolution of the Appeal within the required time frame is an Action and the Enrollee is allowed to file a request for a State fair hearing as the Enrollee has already exhausted the Contractor’s internal appeals process. The Contractor may not require the Enrollee to go through the Contractor’s internal appeals process again. (C) When issuing a Notice of Action due to failure to resolve an Appeal within the required timeframe, the Contractor shall include in the Notice of Action information regarding the procedures and timeframes for filing a request for a State fair hearing rather than information on filing an Appeal. The Contractor shall also attach to the Notice of Action a copy of the request form for a State fair hearing that the Enrollee can submit to request a State fair hearing.

Action Due to Failure to Resolve Appeals or Grievances Within Prescribed Timeframes. (A) Failure of the Contractor to act within the prescribed timeframes provided for resolving and giving resolution notice for Appeals or Grievances constitutes an Action. The Contractor shall provide a Notice of Action to the Aggrieved Party at the time the Contractor determines the time frame for resolving the Appeal or Grievance will not be met. (B) If the Contractor does not resolve an Appeal within the required time frame, Aggrieved Party shall be considered as having completed the Contractor’s Appeal process. The Contractor’s failure to provide resolution of the Appeal within the required time frame is an Action and an Aggrieved Party is allowed to file a request for a State fair hearing as the Aggrieved Party has already exhausted the Contractor’s internal appeals process. The Contractor may not require the Aggrieved Party to go through the Contractor’s internal appeals process again. (C) When issuing a Notice of Action due to failure to resolve an Appeal within the required timeframe, the Contractor shall include in the Notice of Action information regarding the procedures and timeframes for filing a request for a State fair hearing rather than information on filing an Appeal. The Contractor shall also attach to the Notice of Action a copy of the request form for a Medicaid State fair hearing that the Aggrieved Party can submit to request a State fair hearing. (D) If the Enrollee is not the Aggrieved Party, the Contractor shall provide the Notice of Action to the Enrollee as well as to the Aggrieved Party.