Beneficiary Problem Resolution Process Clause Samples

The Beneficiary Problem Resolution Process clause establishes a formal procedure for addressing and resolving issues or disputes raised by the beneficiary under an agreement. Typically, this clause outlines the steps the beneficiary must follow to report a problem, such as submitting a written notice, and may specify timelines for response and resolution by the other party. Its core practical function is to ensure that any concerns or disputes are handled in an organized and timely manner, thereby minimizing misunderstandings and facilitating smoother contract performance.
Beneficiary Problem Resolution Process. 1. The Contractor shall establish and comply with a beneficiary problem resolution process. 2. Contractor shall inform subcontractors and providers at the time they enter into a subcontract about: i. The beneficiary’s right to a state fair hearing, how to obtain a hearing and the representation rules at the hearing. ii. The beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing. iii. The beneficiary’s right to give written consent to allow a provider, acting on behalf of the beneficiary, to file an appeal. A provider may file a grievance or request a state fair hearing on behalf of a beneficiary, if the state permits the provider to act as the beneficiary’s authorized representative in doing so. iv. The beneficiary may file a grievance, either orally or in writing, and, as determined by DHCS, either with DHCS or with the Contractor. v. The availability of assistance with filing grievances and appeals. vi. The toll-free number to file oral grievances and appeals. vii. The beneficiary’s right to request continuation of benefits during an appeal or state fair hearing filing although the beneficiary may be liable for the cost of any continued benefits if the action is upheld. viii. Any state determined provider’s appeal rights to challenge the failure of the Contractor to cover a service. 3. The Contractor shall represent the Contractor’s position in fair hearings, as defined in 42 CFR 438.408 dealing with beneficiaries’ appeals of denials, modifications, deferrals or terminations of covered services. The Contractor shall carry out the final decisions of the fair hearing process with respect to issues within the scope of the Contractor’s responsibilities under this Agreement. Nothing in this section is intended to prevent the Contractor from pursuing any options available for appealing a fair hearing decision. i. Pursuant to 42 CFR 438.228, the Contractor shall develop problem resolution processes that enable beneficiary to request and receive review of a problem or concern he or she has about any issue related to the Contractor's performance of its duties, including the delivery of SUD treatment services. 4. The Contractor’s beneficiary problem resolution processes shall include: i. A grievance process; ii. An appeal process; and, iii. An expedited appeal process.
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Beneficiary Problem Resolution Process. 1. The Contractor shall establish and comply with a beneficiary problem resolution process. 2. Contractor shall inform subcontractors and providers at the time they enter into a subcontract about: i. The beneficiary’s right to a state fair hearing, how to obtain a hearing and the representation rules at the hearing. ii. The beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing. iii. The beneficiary’s right to give written consent to allow a provider, acting on behalf of the beneficiary, to file an appeal. A provider may file a grievance or request a state fair hearing on behalf of a beneficiary, if the state permits the provider to act as the beneficiary’s authorized representative in doing so. iv. The beneficiary may file a grievance, either orally or in writing, and, as determined by DHCS, either with DHCS or with the Contractor. v. The availability of assistance with filing grievances and appeals. vi. The toll-free number to file oral grievances and appeals. vii. The beneficiary’s right to request continuation of benefits during an appeal or state fair hearing filing although the beneficiary may be liable for the cost of any continued benefits if the action is upheld. viii. Any state determined provider’s appeal rights to challenge the failure of the Contractor to cover a service.
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