Beneficiary Problem Resolution Processes Clause Samples
The Beneficiary Problem Resolution Processes clause establishes procedures for addressing and resolving issues or disputes raised by beneficiaries under an agreement. Typically, this clause outlines the steps beneficiaries must follow to report a problem, such as submitting a written notice, and may specify timelines for response and resolution, as well as escalation mechanisms if the issue is not resolved at an initial stage. Its core function is to provide a clear, structured method for handling beneficiary concerns, thereby minimizing misunderstandings and ensuring that problems are addressed efficiently and fairly.
Beneficiary Problem Resolution Processes. The Contractor shall establish and comply with a beneficiary problem resolution process.
A. General Provisions contract about:
1) The beneficiary’s right to a State fair hearing, how to obtain a hearing and the representation rules at the hearing.
2) The beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing.
3) 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 enrollee's authorized representative in doing so.
4) The beneficiary may file a grievance either orally or in writing and, as determined by DHCS, either with the DHCS or with the Contractor.
5) The availability of assistance with filing grievances and appeals.
6) The toll-free number to file oral grievances and appeals.
7) 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.
8) Any State determined provider’s appeal rights to challenge the failure of the Contractor to cover a service.
B. 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 Intergovernmental Agreement. Nothing in this section is intended to prevent the Contractor from pursuing any options available for appealing a fair hearing decision.
1) 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.
2) The Contractor’s beneficiary problem resolution processes shall include:
a) A grievance process;
b) An appeal process; and
c) An expedited appeal process.
3) For the grievance, appeal, and expedited appeal processes, described in 42 CFR. 438 Subpart F, the Contractor shall comply with all of the following requirements:
a) Dispose of each grievance and resolve each appeal, an...
Beneficiary Problem Resolution Processes. The Contractor shall comply with the beneficiary problem resolution process which includes the following:
a. The beneficiary’s right to a State Fair Hearing, how to obtain a hearing and the representation rules at the hearing.
b. The beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing.
c. The beneficiary’s right to give written consent to allow a provider, acting on behalf of the beneficiary, to file an appeal.
d. The beneficiary may file a grievance either orally or in writing and, as determined by DHCS, either with the DHCS or with the County.
e. The availability of assistance with filing grievances and appeals.
f. Provide beneficiaries with the available toll-free numbers to file oral grievances and appeals.
g. 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.
h. Any State determined provider’s appeal rights to challenge the failure of the Provider to cover a service.
i. Pursuant to 438 Subpart F, the Contractor must post notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff.
j. Pursuant to 42 CFR 438.10, making available forms that may be used to file grievances, appeals, and expedited appeals and self-addressed envelopes that beneficiaries can access at all Contract provider sites without having to make a verbal or written request to anyone.
k. A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal.
l. Pursuant to 438.240 related to record keeping and review requirements, identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the County, the provider, and the beneficiary.
m. Pursuant to 42 CFR 438.410(b), ensure that punitive action is not taken against a beneficiary or a provider because they request an expedited appeal or support a beneficiary’s request for an expedited appeal.
n. Provider shall provide the client/beneficiary with a Notice of Adverse Benefits Determination (NOABD) as set forth in the County’s governing beneficiary protections policy and procedures.
Beneficiary Problem Resolution Processes. The Contractor shall establish and comply with a beneficiary problem resolution process.
A. General Provisions contract about:
1) The beneficiary’s right to a State fair hearing, how to obtain a hearing and the representation rules at the hearing.
2) The beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing.
3) 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 enrollee's authorized representative in doing so.
4) The beneficiary may file a grievance either orally or in writing and, as determined by DHCS, either with the DHCS or with the Contractor.
5) The availability of assistance with filing grievances and appeals.
6) The toll-free number to file oral grievances and appeals.
7) 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.
8) Any State determined provider’s appeal rights to challenge the failure of the Contractor to cover a service.
Beneficiary Problem Resolution Processes. 1. The Contractor shall maintain beneficiary problem resolution processes in accordance with Title 42, CFR, Chapter Subchapter C, Part 438, Subpart F, "Grievance Systems," and the Medi-Cal Specialty Mental Health Services Consolidation waiver renewal request as approved by the Centers for Medicare and Medicaid Services on April 24, 2003 and August 22, 2003, that enable beneficiaries to resolve concerns or complaints about any specialty mental health service-related issue. Notwithstanding Title 9, Section 1850.205, the Contractor's beneficiary problem resolution processes shall include a grievance .process, an appeal process, and an expedited appeal process as described in this Section. For the purposes of this contract Section, the following definitions apply:
Beneficiary Problem Resolution Processes. The Contractor shall establish and comply with a beneficiary problem resolution process.
A. General Provisions Contractor shall inform subcontractors and providers at the time they enter into a contract about:
1) The beneficiary’s right to a State fair hearing, how to obtain a hearing and the representation rules at the hearing.
2) The beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing.
3) 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 enrollee's authorized representative in doing so.
4) The beneficiary may file a grievance either orally or in writing and, as determined by DHCS, either with the DHCS or with the Contractor.
5) The availability of assistance with filing grievances and appeals.
6) The toll-free number to file oral grievances and appeals.
7) 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.
8) Any State determined provider’s appeal rights to challenge the failure of the Contractor to cover a service.
Beneficiary Problem Resolution Processes