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.

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.

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 non-compliance with 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.

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.

Appeal Procedure. The definition of an An appeal is an 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 can take when Saint ▇▇▇▇▇▇▇ LIFE Provider: • will not cover or pay for a service or reduces or denies a service request. At the time of enrollment and at least annually thereafter Saint ▇▇▇▇▇▇▇ LIFE will tell you, your caregiver, or authorized representative about the appeals process and provide you with the information in writing. If you, your caregiver, or designated representative request to start, continue or modify a certain service, your request will be brought to the team as quickly as possible, but no later than three (3) calendar days from the time the request is made. The Saint ▇▇▇▇▇▇▇ LIFE team will look at the request to evaluate if the services is necessary to meet the participant’s medical, physical, emotional, and social needs. A member of the team will notify you or your designated representative of their decision to approve, deny or partially deny the requested service as quickly as your condition requires, but no later than three (3) calendar days from the time the request is brought to the team. The member will explain why the requested service is not a necessary service to improve or maintain your overall health status and tell you that you are requesting. • denies, reduces, or terminates have a service. • is denying enrollment into LIFE. • is initiating an involuntary disenrollment from LIFE. The notice will instruct you on how right to appeal the decision if you do not agree with the decision. You must request an will also receive a letter from ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE with the explanation in writing and receive a copy of your appeal within rights. All appeals will remain private. You or your designated representative have 30 calendar days of from the date you receive the notice was sent denial letter from ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE to request an appeal. Should 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 your designated representative choose to appeal the service area for more denied or partially denied service, please contact your Social Worker. Your Social Worker will tell you how the appeals process works and can help you file your appeal if you so desire. ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will respond to and make a decision to resolve your appeal as quickly as your health condition requires, but no later than 30 calendar days without prior approved arrangementsafter we receive your request to appeal. Everyone who has an interest in the appeal, including you, will automatically be considered an appealhave a chance to give facts about the appeal in person, and/or in writing. • Confirmation of receipt of your request for Your appeal will be sent to you within 24 hours of receipt reviewed by an individual who was not involved in the original service request decision. This individual is a well-qualified professional and impartial third party, who does not have a stake in the result of your requestappeal. • Your You or your representative may give facts about your appeal to this individual in writing, over the phone, or in person. During the appeals process if you are enrolled in Medicaid, Saint ▇▇▇▇▇▇▇ LIFE Provider will continue to furnish disputed provide services until a final determination decision is made if you appeal within 30 calendar days of under the notice following conditions: • If Saint ▇▇▇▇▇▇▇ LIFE wants to you. o If your LIFE Provider is proposing to terminate end or reduce services being given, you may request that those services continue during the appeal process. • If you choose to continue the services, you may be have to pay for those service if the appeal is not decided in your favor. Saint ▇▇▇▇▇▇▇ LIFE will continue to provide all other 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 lifelife or health is in danger without the denied or partially denied service, health, or ability ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will respond 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 processas quickly as your health calls for or within seventy- two (72) hours after ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE receives your request to appeal. This is called an expedited appeal. You will receive the outcome of the This expedited appeal within 72 hours of receipt of your appeal. may be increased to fourteen (14) days if you ask for more time or if ▇▇▇▇▇ ▇▇▇▇▇▇▇ 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 can explain to the Department there State Administering Agency (SAA) more time is a need needed for additional information and how it would be in the delay participant’s best interest. If the appeal decision is made in your interestfavor, ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will notify you and provide the requested service as quickly as your health requires. If the decision of the Impartial third party is not made in your favor, ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will notify you, the Center for Medicare and Medicaid Services, and the State Administering Agency (SAA) in writing. If you choose, you may also file an appeal under Medicare or Medicaid. ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will help you or your representative to file this appeal to Medicare, or Medicaid or both. The process you choose depends upon whether you are eligible for Medicare, Medicaid, OR eligible for both Medicaid and Medicare. If you are enrolled in both Medicare and Medicaid OR Medicaid only, you or your designated representative have the right to request a State Fair Hearing by contacting: If you are enrolled in both Medicare and Medicaid OR Medicare only, you or your designated representative may use Medicare’s external appeal process. Your Saint ▇▇▇▇▇▇▇ LIFE Social Worker will assist you with your appeal. As a participant in LIFE you have the following rights: You have the right to be treated with dignity and respect at all times, to have all of your care kept private and to get compassionate, considerate care. • Get all of your health care in a safe, clean environment in an accessible manner. • Be free from harm. This includes receiving excessive medicines; Physical or Mental abuse or neglect; Physical punishment; being placed alone against your will; or have any physical or chemical restraint used on you for discipline or convenience of staff. This is not medicine that you need to treat your health conditions or to prevent injury. • Use your rights in the Saint ▇▇▇▇▇▇▇ LIFE program. • Get help, if you need it, to use the Medicare and Medicaid complaint and appeal processes, as well as your civil and other legal rights. • Be encouraged and helped in talking to ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE staff about changes in policy and services you think should be made. • Use a telephone while at the Saint ▇▇▇▇▇▇▇ LIFE Center. • Not to have to do work or services for the Saint ▇▇▇▇▇▇▇ LIFE program. • Each participant has the right to considerate respectful care from all Saint ▇▇▇▇▇▇▇ LIFE staff members and contractors at all times. • Each participant has the right not to be discriminated against in the delivery of required PACE services based on: Race / Ethnic Origin, Religion, Age, Sex, Mental or physical ability, Sexual Orientation, or Source of payment for your health care (For example, Medicare or Medicaid). • Discrimination is against the law. Every company or agency that works with Medicare and Medicaid must obey the law. • If you think you have been discriminated against for any of these reasons, inform a ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE staff member to assist you with your concern. • If you have any questions, you can call the Office for Civil Rights at Toll free: ▇-▇▇▇-▇▇▇-▇▇▇▇. TTD/TTY users should call ▇-▇▇▇-▇▇▇-▇▇▇▇.