Denials. The CONTRACTOR shall: (a) clearly document in English or other prevalent language, as appropriate, on a form agreed to by HSD, and communicate in writing the reasons for any denial to requesting Network Providers, Non-Network Providers, and the Member; (b) establish and maintain a well-publicized internal and accessible Grievance and Appeal mechanism for both Providers and Members. The notification of a denial shall include a description of how to file a Grievance and Appeal in the CONTRACTOR’s system and how to obtain an HSD Fair Hearing, see 42 C.F.R. §438, subparts (H) and (F); and (c) recognize that a UR decision resulting from HSD Fair Hearing conducted by the designated HSD official is final and shall be honored by the CONTRACTOR. However, the CONTRACTOR shall have the right to dispute the financial responsibility for the decision through the dispute resolution process set forth in this Agreement and seek judicial review of HSD’s Fair Hearing decision.
Appears in 2 contracts
Sources: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Denials. The CONTRACTOR shall:
(a) clearly document in English or other prevalent language, as appropriate, on a form agreed to by HSDthe State, and communicate in writing the reasons for any such denial to requesting Network Providers, Non-Network Providers, and the Member;
(b) establish and maintain a well-publicized internal and accessible Grievance and Appeal mechanism for both Providers and Members. The , the notification of a denial shall include a description of how to file a Grievance and Appeal in the CONTRACTOR’s system and how to obtain an HSD HSD/MAD Fair Hearing, see 42 C.F.R. §438, subparts (H) and (F); and
(c) recognize that a UR decision resulting from HSD HSD/MAD Fair Hearing conducted by the designated HSD HSD/MAD official is final and shall be honored by the CONTRACTOR. However, the CONTRACTOR shall have the right to dispute the financial responsibility for the decision through the dispute resolution process set forth in this Agreement and seek judicial review of HSD/MAD’s Fair Hearing decision.
Appears in 1 contract
Sources: Medicaid Long Term Services Agreement (Amerigroup Corp)