Common use of Beneficiary Problem Resolution Processes Clause in Contracts

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.