Beneficiary Problem Resolution Processes Sample Clauses

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, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the DHCS established timeframes; b) Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following actions; i. Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 14 of this Intergovernmental Agreement; ii. Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to 42 CFR 438.404. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain SUD treatment services; and iii. 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 Contractor provider sites without having to make a verbal or written request to anyone. c) Pursuant to 42 CFR 438.406(a)(1), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability; d) Pursuant to 42 CFR 438.406(a)(2), the Contractor shall acknowledge receipt of each grievance, appeal, and request for expedited appeal to the beneficiary in writing regardless of whether the appeal was received in writing or orally; e) Consistent with 42 CFR 438.402(b)(1)(ii), a beneficiary may authorize, in writing, another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider consents; f) Consistent with 42 CFR 438.402(b)(2), 42 CFR 438.408(f)(1), California Welfare and Institutions Code section 10951, the beneficiary, or provider acting on behalf of the beneficiary, may file an appeal within 90 days of the date on the notice of action was taken; g) A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's behalf. h) At the beneficiary’s request, the Contractor shall identify staff or another individual, such as a legal guardian, to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing SUD treatment services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that beneficiary; i) A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal; j) Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s information; k) A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by 42 CFR 438.240; l) Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal pursuant to 42 CFR 438.406(a)(3)(i); and m) The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity pursuant to Title per 42, CFR 438.406(a)(3)(ii) or Title 22, Sections 51303 and 51340.1. 4) Pursuant to record keeping and review requirements in 42 CFR 438.416, and to facilitate monitoring consistent with 42 CFR 438.240 the Contractor shall: a) Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the problem; b) Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log; c) Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal; d) Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in writing; e) Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary; f) Notify the beneficiary, in writing, of the final disposition of the problem resolution process including the reasons for the disposition; and g) Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal. C. Notice to Beneficiaries Notice to beneficiaries shall be in writing and shall explain the following: 1) The action that the Contractor or its subcontractor has taken or intends to take; 2) The reasons for the action; 3) The beneficiary’s or the provider’s right to file a PIHP appeal; 4) The beneficiary’s right to request a State fair hearing; 5) The procedures for exercising a grievance and/or appeal; 6) The circumstances under which expedited resolution is available and how to request it; and 7) The beneficiary’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the beneficiary may be required of these services. Notices shall be available in the State-established prevalent non-English language in Contractor’s service area and be available in alternative formats for persons with special needs, and use easily understood language and format. D. Grievance Process Consistent with 42 CFR §§ 438.400, 438.402, 438.406, the Contractor shall ensure that its grievance process contains provisions that, at a minimum: 1) Allow beneficiaries or Contractor to present their grievance orally, or in writing; 2) Provide for a decision on the grievance, as expeditiously as the enrollee’s health condition requires, and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; and 3) Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be contacted. E. Appeal Process 1) Consistent with 42 CFR 438.408, the Contractor shall ensure that its appeal process, at a minimum: a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the enrollee or the provider requests expedited resolution pursuant to 42 CFR 438.406(b)(1); . b) Allow a beneficiary to file an appeal orally or in writing pursuant to 42 CFR 438.402(b)(3)(ii); c) Pursuant to 42 CFR 438.402(b)(3)(ii), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes; d) Pursuant to 42 CFR 438.408(b) and (c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal, or as expeditiously as the enrollee's health condition requires. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; e) Consistent with 42 CFR 438.408(f), inform the beneficiary of his or her right to request a fair hearing; f) Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election; g) Allow the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary; and h) Allow the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal. 2) Pursuant to 42 CFR 438.420(a) and (b), the Contractor shall continue the beneficiary’s benefits while an appeal is in process if all of the following conditions are met: a) The appeal was filed on or before the later of the following: within 10 days of the Contractor mailing the notice of action; or the intended effective date of the Contractor’s proposed action; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The authorization period has not expired; and e) The beneficiary requests an extension of benefits. 3) Pursuant to 42 CFR 438.420(c), the Contractor shall continue the beneficiary’s benefits while an appeal is pending until one of the following occurs: a) The beneficiary withdraws the appeal; b) The beneficiary does not request a State Fair Hearing with continuation of benefits within 10 days from the date the Contractor mails an adverse appeal decision; c) A State Fair Hearing decision adverse to the beneficiary is made; or d) The service authorization expires or authorization limits are met. 4) Pursuant to 42 CFR 438.408(e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain: a) The results of the appeal resolution process; b) The date that the appeal decision was made; c) If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain: i. Information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal; and ii. Information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. 5) If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal. 6) Pursuant to 42 CFR 438.420(d), the Contractor may recover the cost of the continued services furnished to the beneficiary while the appeal was pending if the final resolution of the appeal upholds the Contractor’s action. F. Expedited Appeal Process As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum: 1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that taking the time for a standard appeal resolution could seriously jeopardize th

Appears in 2 contracts

Sources: Standard Agreement, Standard Agreement

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, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the DHCS established timeframes; b) Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following actions; i. Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 14 of this Intergovernmental Agreement; ii. Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to 42 CFR 438.404. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain SUD treatment services; and iii. 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 Contractor provider sites without having to make a verbal or written request to anyone. c) Pursuant to 42 CFR 438.406(a)(1), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability; d) Pursuant to 42 CFR 438.406(a)(2), the Contractor shall acknowledge receipt of each grievance, appeal, and request for expedited appeal to the beneficiary in writing regardless of whether the appeal was received in writing or orally; e) Consistent with 42 CFR 438.402(b)(1)(ii), a beneficiary may authorize, in writing, another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider consents; f) Consistent with 42 CFR 438.402(b)(2), 42 CFR 438.408(f)(1), California Welfare and Institutions Code section 10951, the beneficiary, or provider acting on behalf of the beneficiary, may file an appeal within 90 days of the date on the notice of action was taken; g) A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's behalf. h) At the beneficiary’s request, the Contractor shall identify staff or another individual, such as a legal guardian, to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing SUD treatment services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that beneficiary; i) A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal; j) Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s information; k) A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by 42 CFR 438.240; l) Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal pursuant to 42 CFR 438.406(a)(3)(i); and m) The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity pursuant to Title per 42, CFR 438.406(a)(3)(ii) or Title 22, Sections 51303 and 51340.1. 4) Pursuant to record keeping and review requirements in 42 CFR 438.416, and to facilitate monitoring consistent with 42 CFR 438.240 the Contractor shall: a) Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the problem; b) Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log; c) Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal; d) Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in writing; e) Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary; f) Notify the beneficiary, in writing, of the final disposition of the problem resolution process including the reasons for the disposition; and g) Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal. C. Notice to Beneficiaries Notice to beneficiaries shall be in writing and shall explain the following: 1) The action that the Contractor or its subcontractor has taken or intends to take; 2) The reasons for the action; 3) The beneficiary’s or the provider’s right to file a PIHP appeal; 4) The beneficiary’s right to request a State fair hearing; 5) The procedures for exercising a grievance and/or appeal; 6) The circumstances under which expedited resolution is available and how to request it; and 7) The beneficiary’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the beneficiary may be required of these services. Notices shall be available in the State-established prevalent non-English language in Contractor’s service area and be available in alternative formats for persons with special needs, and use easily understood language and format. D. Grievance Process Consistent with 42 CFR §§ 438.400, 438.402, 438.406, the Contractor shall ensure that its grievance process contains provisions that, at a minimum: 1) Allow beneficiaries or Contractor to present their grievance orally, or in writing; 2) Provide for a decision on the grievance, as expeditiously as the enrollee’s health condition requires, and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; and 3) Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be contacted. E. Appeal Process 1) Consistent with 42 CFR 438.408, the Contractor shall ensure that its appeal process, at a minimum: a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the enrollee or the provider requests expedited resolution pursuant to 42 CFR 438.406(b)(1); . b) Allow a beneficiary to file an appeal orally or in writing pursuant to 42 CFR 438.402(b)(3)(ii); c) Pursuant to 42 CFR 438.402(b)(3)(ii), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes; d) Pursuant to 42 CFR 438.408(b) and (c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal, or as expeditiously as the enrollee's health condition requires. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; e) Consistent with 42 CFR 438.408(f), inform the beneficiary of his or her right to request a fair hearing; f) Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election; g) Allow the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary; and h) Allow the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal. 2) Pursuant to 42 CFR 438.420(a) and (b), the Contractor shall continue the beneficiary’s benefits while an appeal is in process if all of the following conditions are met: a) The appeal was filed on or before the later of the following: within 10 days of the Contractor mailing the notice of action; or the intended effective date of the Contractor’s proposed action; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The authorization period has not expired; and e) The beneficiary requests an extension of benefits. 3) Pursuant to 42 CFR 438.420(c), the Contractor shall continue the beneficiary’s benefits while an appeal is pending until one of the following occurs: a) The beneficiary withdraws the appeal; b) The beneficiary does not request a State Fair Hearing with continuation of benefits within 10 days from the date the Contractor mails an adverse appeal decision; c) A State Fair Hearing decision adverse to the beneficiary is made; or d) The service authorization expires or authorization limits are met. 4) Pursuant to 42 CFR 438.408(e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain: a) The results of the appeal resolution process; b) The date that the appeal decision was made; c) If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain: i. Information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal; and ii. Information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. 5) If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal. 6) Pursuant to 42 CFR 438.420(d), the Contractor may recover the cost of the continued services furnished to the beneficiary while the appeal was pending if the final resolution of the appeal upholds the Contractor’s action. F. Expedited Appeal Process As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum: 1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that taking the time for a standard appeal resolution could seriously jeopardize th

Appears in 1 contract

Sources: Standard Agreement

Beneficiary Problem Resolution Processes. ‌ The Contractor shall establish and comply with a beneficiary problem resolution ~~process.~~process.‌ A. General ~~Provisions~~ Provisions‌ Contractor shall inform subcontractors and providers at the time they enter into a contract ~~about:~~about:‌ 1) The beneficiary’s right to a State fair hearing, how to obtain a hearing and the representation rules at the ~~hearing.~~hearing.‌ 2) The beneficiary’s right to file grievances and appeals and the requirements and timeframes for ~~filing.~~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.~~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.~~Contractor.‌ 5) The availability of assistance with filing grievances and ~~appeals.~~appeals.‌ 6) The toll-free number to file oral grievances and ~~appeals.~~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.~~upheld.‌ 8) Any State determined provider’s appeal rights to challenge the failure of the Contractor to cover a ~~service.~~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.~~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.~~services.‌ 2) The Contractor’s beneficiary problem resolution processes shall ~~include:~~include:‌ a) A grievance ~~process;~~process;‌ b) An appeal process; ~~and~~and‌ c) An expedited appeal ~~process.~~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:~~requirements:‌ a) Dispose of each grievance and resolve each appeal, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the DHCS established ~~timeframes;~~timeframes;‌ b) Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following ~~actions;~~actions;‌ i. Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 14 of this Intergovernmental ~~Agreement;~~Agreement;‌ ii. Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to 42 CFR 438.404. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain SUD treatment services; ~~and~~and‌ iii. 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 Contractor provider sites without having to make a verbal or written request to ~~anyone.~~anyone.‌ c) Pursuant to 42 CFR 438.406(a)(1), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter ~~capability;~~capability;‌ d) Pursuant to 42 CFR 438.406(a)(2), the Contractor shall acknowledge receipt of each grievance, appeal, and request for expedited appeal to the beneficiary in writing regardless of whether the appeal was received in writing or orally; e) Consistent with 42 CFR 438.402(b)(1)(ii), a beneficiary may authorize, in writing, another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider ~~consents;~~consents;‌ f) Consistent with 42 CFR 438.402(b)(2), 42 CFR 438.408(f)(1), California Welfare and Institutions Code section 10951, the beneficiary, or provider acting on ~~behalf~~ behalf‌ of the beneficiary, may file an appeal within 90 days of the date on the notice of action was ~~taken;~~taken;‌ g) A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's ~~behalf.~~behalf.‌ h) At the beneficiary’s request, the Contractor shall identify staff or another individual, such as a legal guardian, to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing SUD treatment services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that ~~beneficiary;~~beneficiary;‌ i) A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited ~~appeal;~~appeal;‌ j) Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s ~~information;~~information;‌ k) A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by 42 CFR ~~438.240;~~438.240;‌ l) Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal pursuant to 42 CFR 438.406(a)(3)(i); ~~and~~and‌ m) The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity pursuant to Title per 42, CFR 438.406(a)(3)(ii) or Title 22, Sections 51303 and ~~51340.1.~~51340.1.‌ 4) Pursuant to record keeping and review requirements in 42 CFR 438.416, and to facilitate monitoring consistent with 42 CFR 438.240 the Contractor ~~shall:~~shall:‌ a) Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the ~~problem;~~problem;‌ b) Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log; c) Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited ~~appeal;~~appeal;‌ d) Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in ~~writing;~~writing;‌ e) Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the ~~beneficiary;~~beneficiary;‌ f) Notify the beneficiary, in writing, of the final disposition of the problem resolution process including the reasons for the disposition; ~~and~~and‌ g) Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited ~~appeal.~~appeal.‌ C. Notice to ~~Beneficiaries~~ Beneficiaries‌ Notice to beneficiaries shall be in writing and shall explain the ~~following:~~following:‌ 1) The action that the Contractor or its subcontractor has taken or intends to ~~take;~~take;‌ 2) The reasons for the ~~action;~~action;‌ 3) The beneficiary’s or the provider’s right to file a PIHP ~~appeal;~~appeal;‌ 4) The beneficiary’s right to request a State fair ~~hearing;~~hearing;‌ 5) The procedures for exercising a grievance and/or ~~appeal;~~appeal;‌ 6) The circumstances under which expedited resolution is available and how to request it; ~~and~~and‌ 7) The beneficiary’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the beneficiary may be required of these ~~services.~~ services.‌ Notices shall be available in the State-established prevalent non-English language in Contractor’s service area and be available in alternative formats for persons with special needs, and use easily understood language and ~~format.~~format.‌ ~~D. Grievance Process~~ ▇. ▇▇▇▇▇▇▇▇▇ Process‌ Consistent with 42 CFR §§ 438.400, 438.402, 438.406, the Contractor shall ensure that its grievance process contains provisions that, at a ~~minimum:~~minimum:‌‌ 1) Allow beneficiaries or Contractor to present their grievance orally, or in ~~writing;~~writing;‌ 2) Provide for a decision on the grievance, as expeditiously as the enrollee’s health condition requires, and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; ~~and~~and‌ 3) Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be ~~contacted.~~contacted.‌ E. Appeal ~~Process~~Process‌ 1) Consistent with 42 CFR 438.408, the Contractor shall ensure that its appeal process, at a minimum: a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the enrollee or the provider requests expedited resolution pursuant to 42 CFR ~~438.406(b)(1); .~~438.406(b)(1);‌ b) Allow a beneficiary to file an appeal orally or in writing pursuant to 42 CFR 438.402(b)(3)(ii); ; c) Pursuant to 42 CFR 438.402(b)(3)(ii), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes; d) Pursuant to 42 CFR 438.408(b) and (c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal, or as expeditiously as the enrollee's health condition requires. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; e) Consistent with 42 CFR 438.408(f), inform the beneficiary of his or her right to request a fair hearing; f) Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election; g) Allow the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary; and h) Allow the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal. 2) Pursuant to 42 CFR 438.420(a) and (b), the Contractor shall continue the beneficiary’s benefits while an appeal is in process if all of the following conditions are met: a) The appeal was filed on or before the later of the following: within 10 days of the Contractor mailing the notice of action; or the intended effective date of the Contractor’s proposed action; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The authorization period has not expired; and e) The beneficiary requests an extension of benefits. 3) Pursuant to 42 CFR 438.420(c), the Contractor shall continue the beneficiary’s benefits while an appeal is pending until one of the following occurs: a) The beneficiary withdraws the appeal; b) The beneficiary does not request a State Fair Hearing with continuation of benefits within 10 days from the date the Contractor mails an adverse appeal decision; c) A State Fair Hearing decision adverse to the beneficiary is made; or d) The service authorization expires or authorization limits are met. 4) Pursuant to 42 CFR 438.408(e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain: a) The results of the appeal resolution process; b) The date that the appeal decision was made; c) If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain: i. Information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal; and ii. Information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. 5) If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal. 6) Pursuant to 42 CFR 438.420(d), the Contractor may recover the cost of the continued services furnished to the beneficiary while the appeal was pending if the final resolution of the appeal upholds the Contractor’s action. F. Expedited Appeal Process As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum: 1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that taking the time for a standard appeal resolution could seriously jeopardize thtimeframes;‌

Appears in 1 contract

Sources: Intergovernmental Agreement

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, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the DHCS established timeframes; b) Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following actions; i. Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 14 of this Intergovernmental Agreement; ii. Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to 42 CFR 438.404. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain SUD treatment services; and iii. 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 Contractor provider sites without having to make a verbal or written request to anyone. c) Pursuant to 42 CFR 438.406(a)(1), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability; d) Pursuant to 42 CFR 438.406(a)(2), the Contractor shall acknowledge receipt of each grievance, appeal, and request for expedited appeal to the beneficiary in writing regardless of whether the appeal was received in writing or orally; e) Consistent with 42 CFR 438.402(b)(1)(ii), a beneficiary may authorize, in writing, another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider consents; f) Consistent with 42 CFR 438.402(b)(2), 42 CFR 438.408(f)(1), California Welfare and Institutions Code section 10951, the beneficiary, or provider acting on behalf of the beneficiary, may file an appeal within 90 days of the date on the notice of action was taken; g) A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's behalf. h) At the beneficiary’s request, the Contractor shall identify staff or another individual, such as a legal guardian, to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing SUD treatment services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that beneficiary; i) A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal; j) Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s information; k) A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by 42 CFR 438.240; l) Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal pursuant to 42 CFR 438.406(a)(3)(i); and m) The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity pursuant to Title per 42, CFR 438.406(a)(3)(ii) or Title 22, Sections 51303 and 51340.1. 4) Pursuant to record keeping and review requirements in 42 CFR 438.416, and to facilitate monitoring consistent with 42 CFR 438.240 the Contractor shall: a) Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the problem; b) Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log; c) Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal; d) Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in writing; e) Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary; f) Notify the beneficiary, in writing, of the final disposition of the problem resolution process including the reasons for the disposition; and g) Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal. C. Notice to Beneficiaries Notice to beneficiaries shall be in writing and shall explain the following: 1) The action that the Contractor or its subcontractor has taken or intends to take; 2) The reasons for the action; 3) The beneficiary’s or the provider’s right to file a PIHP appeal; 4) The beneficiary’s right to request a State fair hearing; 5) The procedures for exercising a grievance and/or appeal; 6) The circumstances under which expedited resolution is available and how to request it; and 7) The beneficiary’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the beneficiary may be required of these services. Notices shall be available in the State-established prevalent non-English language in Contractor’s service area and be available in alternative formats for persons with special needs, and use easily understood language and format. D. Grievance Process Consistent with 42 CFR §§ 438.400, 438.402, 438.406, the Contractor shall ensure that its grievance process contains provisions that, at a minimum: 1) Allow beneficiaries or Contractor to present their grievance orally, or in writing; 2) Provide for a decision on the grievance, as expeditiously as the enrollee’s health condition requires, and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; and 3) Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be contacted. E. Appeal Process 1) Consistent with 42 CFR 438.408, the Contractor shall ensure that its appeal process, at a minimum: a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the enrollee or the provider requests expedited resolution pursuant to 42 CFR 438.406(b)(1); . b) Allow a beneficiary to file an appeal orally or in writing pursuant to 42 CFR 438.402(b)(3)(ii); c) Pursuant to 42 CFR 438.402(b)(3)(ii), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes; d) Pursuant to 42 CFR 438.408(b) and (c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal, or as expeditiously as the enrollee's health condition requires. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; e) Consistent with 42 CFR 438.408(f), inform the beneficiary of his or her right to request a fair hearing; f) Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election; g▇) ~~Allow~~ ▇▇▇▇▇ the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary; and h▇) ~~Allow~~ ▇▇▇▇▇ the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal. 2) Pursuant to 42 CFR 438.420(a) and (b), the Contractor shall continue the beneficiary’s benefits while an appeal is in process if all of the following conditions are met: a) The appeal was filed on or before the later of the following: within 10 days of the Contractor mailing the notice of action; or the intended effective date of the Contractor’s proposed action; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The authorization period has not expired; and e) The beneficiary requests an extension of benefits. 3) Pursuant to 42 CFR 438.420(c), the Contractor shall continue the beneficiary’s benefits while an appeal is pending until one of the following occurs: a) The beneficiary withdraws the appeal; b) The beneficiary does not request a State Fair Hearing with continuation of benefits within 10 days from the date the Contractor mails an adverse appeal decision; c) A State Fair Hearing decision adverse to the beneficiary is made; or d) The service authorization expires or authorization limits are met. 4) Pursuant to 42 CFR 438.408(e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain: a) The results of the appeal resolution process; b) The date that the appeal decision was made; c) If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain: i. Information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal; and ii. Information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. 5) If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal. 6) Pursuant to 42 CFR 438.420(d), the Contractor may recover the cost of the continued services furnished to the beneficiary while the appeal was pending if the final resolution of the appeal upholds the Contractor’s action. F. Expedited Appeal Process As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum: 1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that taking the time for a standard appeal resolution could seriously jeopardize th

Appears in 1 contract

Sources: Standard Agreement

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. 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, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the DHCS established timeframes; b) Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following actions; i. Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 14 of this Intergovernmental Agreement; ii. Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to 42 CFR 438.404. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain SUD treatment services; and iii. 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 Contractor provider sites without having to make a verbal or written request to anyone. c) Pursuant to 42 CFR 438.406(a)(1), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability; d) Pursuant to 42 CFR 438.406(a)(2), the Contractor shall acknowledge receipt of each grievance, appeal, and request for expedited appeal to the beneficiary in writing regardless of whether the appeal was received in writing or orally; e) Consistent with 42 CFR 438.402(b)(1)(ii), a beneficiary may authorize, in writing, another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider consents; f) Consistent with 42 CFR 438.402(b)(2), 42 CFR 438.408(f)(1), California Welfare and Institutions Code section 10951, the beneficiary, or provider acting on behalf of the beneficiary, may file an appeal within 90 days of the date on the notice of action was taken; g) A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's behalf. h) At the beneficiary’s request, the Contractor shall identify staff or another individual, such as a legal guardian, to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing SUD treatment services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that beneficiary; i) A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal; j) Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s information; k) A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by 42 CFR 438.240; l) Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal pursuant to 42 CFR 438.406(a)(3)(i); and m) The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity pursuant to Title per 42, CFR 438.406(a)(3)(ii) or Title 22, Sections 51303 and 51340.1. 4) Pursuant to record keeping and review requirements in 42 CFR 438.416, and to facilitate monitoring consistent with 42 CFR 438.240 the Contractor shall: a) Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the problem; b) Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log; c) Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal; d) Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in writing; e) Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary; f) Notify the beneficiary, in writing, of the final disposition of the problem resolution process including the reasons for the disposition; and g) Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal. C. Notice to Beneficiaries Notice to beneficiaries shall be in writing and shall explain the following: 1) The action that the Contractor or its subcontractor has taken or intends to take; 2) The reasons for the action; 3) The beneficiary’s or the provider’s right to file a PIHP appeal; 4) The beneficiary’s right to request a State fair hearing; 5) The procedures for exercising a grievance and/or appeal; 6) The circumstances under which expedited resolution is available and how to request it; and 7) The beneficiary’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the beneficiary may be required of these services. Notices shall be available in the State-established prevalent non-English language in Contractor’s service area and be available in alternative formats for persons with special needs, and use easily understood language and format. ~~D. Grievance~~ ▇. ▇▇▇▇▇▇▇▇▇ Process Consistent with 42 CFR §§ 438.400, 438.402, 438.406, the Contractor shall ensure that its grievance process contains provisions that, at a minimum: 1) Allow beneficiaries or Contractor to present their grievance orally, or in writing; 2) Provide for a decision on the grievance, as expeditiously as the enrollee’s health condition requires, and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; and 3) Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be contacted. E. Appeal Process 1) Consistent with 42 CFR 438.408, the Contractor shall ensure that its appeal process, at a minimum: a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the enrollee or the provider requests expedited resolution pursuant to 42 CFR 438.406(b)(1); . b) Allow a beneficiary to file an appeal orally or in writing pursuant to 42 CFR 438.402(b)(3)(ii); c) Pursuant to 42 CFR 438.402(b)(3)(ii), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes; d) Pursuant to 42 CFR 438.408(b) and (c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal, or as expeditiously as the enrollee's health condition requires. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; e) Consistent with 42 CFR 438.408(f), inform the beneficiary of his or her right to request a fair hearing; f) Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election; g▇) ~~Allow~~ ▇▇▇▇▇ the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary; and h▇) ~~Allow~~ ▇▇▇▇▇ the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal. 2) Pursuant to 42 CFR 438.420(a) and (b), the Contractor shall continue the beneficiary’s benefits while an appeal is in process if all of the following conditions are met: a) The appeal was filed on or before the later of the following: within 10 days of the Contractor mailing the notice of action; or the intended effective date of the Contractor’s proposed action; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The authorization period has not expired; and e) The beneficiary requests an extension of benefits. 3) Pursuant to 42 CFR 438.420(c), the Contractor shall continue the beneficiary’s benefits while an appeal is pending until one of the following occurs: a) The beneficiary withdraws the appeal; b) The beneficiary does not request a State Fair Hearing with continuation of benefits within 10 days from the date the Contractor mails an adverse appeal decision; c) A State Fair Hearing decision adverse to the beneficiary is made; or d) The service authorization expires or authorization limits are met. 4) Pursuant to 42 CFR 438.408(e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain: a) The results of the appeal resolution process; b) The date that the appeal decision was made; c) If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain: i. Information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal; and ii. Information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. 5) If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal. 6) Pursuant to 42 CFR 438.420(d), the Contractor may recover the cost of the continued services furnished to the beneficiary while the appeal was pending if the final resolution of the appeal upholds the Contractor’s action. F. Expedited Appeal Process As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum: 1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies ~~that taking the time for a standard appeal resolution could seriously jeopardize th~~

Appears in 1 contract

Sources: Intergovernmental Agreement

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. 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, and provide notice, as expeditiously as the beneficiary’s health condition requires, within the DHCS established timeframes; b) Assure that each beneficiary has adequate information about the Contractor's problem resolution processes by taking at least the following actions; i. Including information describing the grievance, appeal, and expedited appeal processes in the Contractor's beneficiary booklet and providing the beneficiary booklet to beneficiaries as described in Section 14 of this Intergovernmental Agreement; ii. Posting notices explaining grievance, appeal, and expedited appeal process procedures in locations at all Contractor provider sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings or expedited appeal process, including information that a fair hearing may be requested whether or not the beneficiary has received a notice of action pursuant to 42 CFR 438.404. For the purposes of this Section, a Contractor provider site means any office or facility owned or operated by the Contractor or a provider contracting with the Contractor at which beneficiaries may obtain SUD treatment services; and iii. 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 Contractor provider sites without having to make a verbal or written request to anyone. c) Pursuant to 42 CFR 438.406(a)(1), giving beneficiaries any reasonable assistance in completing the forms and other procedural steps not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability; d) Pursuant to 42 CFR 438.406(a)(2), the Contractor shall acknowledge receipt of each grievance, appeal, and request for expedited appeal to the beneficiary in writing regardless of whether the appeal was received in writing or orally; e) Consistent with 42 CFR 438.402(b)(1)(ii), a beneficiary may authorize, in writing, another person to act on the beneficiary's behalf. The beneficiary may select a provider as his or her representative in the appeal or expedited appeal process, if the provider consents; f) Consistent with 42 CFR 438.402(b)(2), 42 CFR 438.408(f)(1), California Welfare and Institutions Code section 10951, the beneficiary, or provider acting on behalf of the beneficiary, may file an appeal within 90 days of the date on the notice of action was taken; g) A beneficiary's legal representative may use the grievance, appeal, or expedited appeal processes on the beneficiary's behalf. h) At the beneficiary’s request, the Contractor shall identify staff or another individual, such as a legal guardian, to be responsible for assisting a beneficiary with these processes, including providing assistance in writing the grievance, appeal, or expedited appeal. If the individual identified by the Contractor is the person providing SUD treatment services to the beneficiary requesting assistance, the Contractor shall identify another individual to assist that beneficiary; i) A beneficiary shall not be subject to discrimination or any other penalty for filing a grievance, appeal, or expedited appeal; j) Procedures for these beneficiary problem resolution processes shall maintain the confidentiality of each beneficiary’s information; k) A procedure shall be included by which issues identified as a result of the grievance, appeal or expedited appeal processes are transmitted to the Contractor's Quality Improvement Committee, the Contractor's administration or another appropriate body within the Contractor’s operations. These issues shall be considered in the Contractor's Quality Improvement Program, as required by 42 CFR 438.240; l) Individuals involved in any previous review or decision-making on the issue(s) presented in a problem resolution process shall not participate in making the decision on the grievance, appeal, or expedited appeal pursuant to 42 CFR 438.406(a)(3)(i); and m) The individual making the decision on the grievance, appeal, or expedited appeal shall have the appropriate clinical expertise, as determined by the Contractor, required to treat the beneficiary's condition, if the grievance concerns the denial of a request for an expedited appeal or if the grievance, appeal, or expedited appeal addresses any clinical issue, including a lack of medical necessity pursuant to Title per 42, CFR 438.406(a)(3)(ii) or Title 22, Sections 51303 and 51340.1. 4) Pursuant to record keeping and review requirements in 42 CFR 438.416, and to facilitate monitoring consistent with 42 CFR 438.240 the Contractor shall: a) Maintain a grievance and appeal log and record grievances, appeals, and expedited appeals in the log within one working day of the date of receipt of the grievance or appeal. The log entry shall include, but not be limited to, the name of the beneficiary, the date of receipt of the grievance, appeal, or expedited appeal, and the nature of the problem; b) Record in the grievance and appeal log or another central location determined by the Contractor, the final dispositions of grievances, appeals, and expedited appeals, including the date the decision is sent to the beneficiary. If there has not been final disposition of the grievance, appeal, or expedited appeal, the reason(s) shall be included in the log; c) Provide a staff person or other individual with responsibility to provide information requested by the beneficiary or the beneficiary’s representative regarding the status of the beneficiary's grievance, appeal, or expedited appeal; d) Acknowledge the receipt of each grievance, appeal, and expedited appeal to the beneficiary in writing; e) Identify in its grievance, appeal, and expedited appeal documentation, the roles and responsibilities of the Contractor, the provider, and the beneficiary; f) Notify the beneficiary, in writing, of the final disposition of the problem resolution process including the reasons for the disposition; and g) Notify, in writing, any provider identified by the beneficiary or involved in the grievance, appeal, or expedited appeal of the final disposition of the beneficiary's grievance, appeal, or expedited appeal. C. Notice to Beneficiaries Notice to beneficiaries shall be in writing and shall explain the following: 1) The action that the Contractor or its subcontractor has taken or intends to take; 2) The reasons for the action; 3) The beneficiary’s or the provider’s right to file a PIHP appeal; 4) The beneficiary’s right to request a State fair hearing; 5) The procedures for exercising a grievance and/or appeal; 6) The circumstances under which expedited resolution is available and how to request it; and 7) The beneficiary’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the beneficiary may be required of these services. Notices shall be available in the State-established prevalent non-English language in Contractor’s service area and be available in alternative formats for persons with special needs, and use easily understood language and format. D. Grievance Process Consistent with 42 CFR §§ 438.400, 438.402, 438.406, the Contractor shall ensure that its grievance process contains provisions that, at a minimum: 1) Allow beneficiaries or Contractor to present their grievance orally, or in writing; 2) Provide for a decision on the grievance, as expeditiously as the enrollee’s health condition requires, and notify the affected parties within 60 calendar days of receipt of the grievance. This timeframe may be extended by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframe, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; and 3) Provide for notification of the beneficiary or the appropriate representative in writing of the grievance decision and documentation of the notification or efforts to notify the beneficiary, if he or she could not be contacted. E. Appeal Process 1) Consistent with 42 CFR 438.408, the Contractor shall ensure that its appeal process, at a minimum: a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the enrollee or the provider requests expedited resolution pursuant to 42 CFR 438.406(b)(1); . b) Allow a beneficiary to file an appeal orally or in writing pursuant to 42 CFR 438.402(b)(3)(ii); c) Pursuant to 42 CFR 438.402(b)(3)(ii), require a beneficiary who makes an oral appeal, that is not an expedited appeal, to subsequently submit the appeal in writing. The date the Contractor receives the oral appeal shall be considered the filing date for the purpose of applying the appeal timeframes; d) Pursuant to 42 CFR 438.408(b) and (c), provide for a decision on the appeal and notify the affected parties within 45 calendar days of receipt of the appeal, or as expeditiously as the enrollee's health condition requires. This timeframe may be extended by up to 14 calendar days, if the beneficiary requests an extension or the Contractor determines that there is a need for additional information and that the delay is in the beneficiary's interest. If the Contractor extends the timeframes, the Contractor shall, for any extension not requested by the beneficiary, notify the beneficiary of the extension and the reasons for the extension in writing. The written notice of the extension is not a Notice of Action as defined in 42 CFR 438.210; e) Consistent with 42 CFR 438.408(f), inform the beneficiary of his or her right to request a fair hearing; f) Allow the beneficiary to have a reasonable opportunity to present evidence and arguments of fact or law, in person and/or in writing, in accordance with the beneficiary’s election; g) Allow the beneficiary and/or his or her representative to examine the beneficiary's case file, including medical records, and any other documents or records considered before and during the appeal process, provided that there is no disclosure of the protected health information of any individual other than the beneficiary; and h) Allow the beneficiary and/or his or her representative, or the legal representative of a deceased beneficiary's estate, to be included as parties to the appeal. 2) Pursuant to 42 CFR 438.420(a) and (b), the Contractor shall continue the beneficiary’s benefits while an appeal is in process if all of the following conditions are met: a) The appeal was filed on or before the later of the following: within 10 days of the Contractor mailing the notice of action; or the intended effective date of the Contractor’s proposed action; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The authorization period has not expired; and e) The beneficiary requests an extension of benefits. 3) Pursuant to 42 CFR 438.420(c), the Contractor shall continue the beneficiary’s benefits while an appeal is pending until one of the following occurs: a) The beneficiary withdraws the appeal; b) The beneficiary does not request a State Fair Hearing with continuation of benefits within 10 days from the date the Contractor mails an adverse appeal decision; c) A State Fair Hearing decision adverse to the beneficiary is made; or d) The service authorization expires or authorization limits are met. 4) Pursuant to 42 CFR 438.408(e), the Contractor shall notify the beneficiary, and/or his or her representative, of the resolution of the appeal in writing. The notice shall contain: a) The results of the appeal resolution process; b) The date that the appeal decision was made; c) If the appeal is not resolved wholly in favor of the beneficiary, the notice shall also contain: i. Information regarding the beneficiary's right to a fair hearing and the procedure for filing for a fair hearing, if the beneficiary has not already requested a fair hearing on the issue involved in the appeal; and ii. Information on the beneficiary’s right to continue to receive benefits while the fair hearing is pending and how to request the continuation of benefits. 5) If the decision of the appeal resolution process reverses a decision to deny, limit or delay services, the Contractor shall promptly provide or arrange and pay for the services at issue in the appeal. 6) Pursuant to 42 CFR 438.420(d), the Contractor may recover the cost of the continued services furnished to the beneficiary while the appeal was pending if the final resolution of the appeal upholds the Contractor’s action. F. Expedited Appeal Process As defined in 42 CFR 438.400, to the expedited appeal process shall be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies that following the timeframe for an appeal as established in 42 CFR 438.408, would seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. In addition to meeting the requirements of 42 CFR 438.410(a), 42 CFR 438.406(b), the Contractor shall ensure that its expedited appeal process, at a minimum: 1) Be used when the Contractor determines or the beneficiary and/or the beneficiary's provider certifies ~~that taking the time for a standard appeal resolution could seriously jeopardize th~~

Appears in 1 contract

Sources: Intergovernmental Agreement

Common use of Beneficiary Problem Resolution Processes Clause in Contracts