Expedited Appeal Process Sample Clauses
Expedited Appeal Process. The process by which the Appeal of an Action is accelerated because the standard time-frame for resolution of the Appeal could seriously jeopardize the Enrollee's life, health or ability to obtain, maintain or regain maximum function.
Expedited Appeal Process. CHA PACE has an expedited appeal process for situations in which you and/or your caregiver/ family believe that your life, health or ability to regain maximum function would be seriously jeopardized, absent provision of the service in dispute. • CHA PACE will respond to the appeal in the same manner as described in the standard appeal process, as expeditiously as the participant’s health condition requires, but no later than 72 hours after it receives the appeal. • CHA PACE may extend the 72-hour time frame by up to 14 calendar days for either of the following reasons: » You request an extension » CHA PACE justifies to the MassHealth the need for additional information and how the delay is in your best interest In the event that the determination is in your favor, CHA PACE will furnish the disputed service(s) as expeditiously as the participant’s health condition requires.
Expedited Appeal Process. The Contractor shall establish and maintain an Expedited Appeal Process for Appeals when the Contractor determines or a BHA indicates that taking the time for a standard resolution of an Appeal could seriously jeopardize the Enrollee’s life or health and ability to attain, maintain, or regain maximum function (42 CFR § 438.410(a)).
6.5.1. If the Contractor denies the request for the expedited Appeal and resolution of an Appeal, it must transfer the Appeal to the timeframe for standard resolutions under subsection 8.5 of this Agreement, and make reasonable efforts to give the Enrollee prompt oral notice of the denial and follow up within two (2) calendar days with a written Notice.
6.5.2. Both of the following apply to Expedited Appeal requests:
6.5.2.1. The Action taken on the Notice of Action is for termination, suspension, or reduction of previously authorized behavioral health services; and
6.5.2.2. The Enrollee, the Enrollee’s Authorized Representative, or a BHA acting on behalf of the Enrollee and with the Enrollee’s written consent, may file an Appeal with the Contractor, either orally or in writing, within ten (10) calendar days from the date on the Contractor’s written Notice of Action that communicated the Action.
6.5.3. The Enrollee may ask for continued mental health services pending the outcome of the Expedited Appeal.
6.5.4. The Contractor shall make a decision on the Enrollee’s request for Expedited Appeal and provide written Notice, as expeditiously as the Enrollee’s condition requires, within two (2) calendar days after the Contractor receives the Appeal. (42 CFR § 438.408(b)(3)). The Contractor shall also make reasonable efforts to provide oral notice.
6.5.5. The Contractor shall ensure that punitive action is not taken against a BHA who requests an expedited resolution or supports an Enrollee’s Appeal (42 CFR § 438.410(b)).
6.5.6. The Contractor may extend the timeframe up to 14 additional calendar days if the Enrollee requests an extension or the Contractor can demonstrate that it needs additional information and that the added time is in the Enrollee’s interest.
6.5.7. For any extension not requested by an Enrollee, the Contractor must give the Enrollee written notice of the reason for the delay.
6.5.8. The Enrollee has a right to file a Grievance regarding the Contractor’s denial of a request for expedited resolution. The Contractor shall inform the Enrollee of their right to file a Grievance in the Notice of denial.
Expedited Appeal Process. The process by which the appeal of a Managed Care Plan’s adverse benefit determination is accelerated because the standard timeframe for resolution of the plan appeal could seriously jeopardize the enrollee’s life, health or ability to obtain, maintain or regain maximum function.
Expedited Appeal Process. 10.4.1 The Contractor shall establish and maintain an expedited appeal review process for appeals when the Contractor determines, for a request from the enrollee, or the provider indicates, in making the request on the enrollee’s behalf or supporting the enrollee’s request, that taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function.
10.4.2 The Contractor shall make a decision on the enrollee’s request for expedited appeal and provide notice, as expeditiously as the enrollee’s health condition requires, within three (3) calendar days after the Contractor receives the appeal. The Contractor shall also make reasonable efforts to provide oral notice.
10.4.3 The Contractor shall ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal.
10.4.4 If the Contractor denies a request for expedited resolution of an appeal, it shall transfer the appeal to the timeframe for standard resolution and make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice.
10.4.5 The enrollee has a right to file a grievance regarding the Contractors denial of a request for expedited resolution. The Contractor must inform the enrollee of their right to file a grievance in the notice of denial.
Expedited Appeal Process. In situations in which you believe that if a service is not furnished, your life, health, or ability to regain or maintain maximum function could be jeopardized, the appeals process will be expedited if you inform us of this. A decision will be reached on an expedited appeal within 72 hours after the appeal is received. The 72 hour time frame may be extended by up to 14 calendar days if you request the extension or if PACE CNY justifies to the New York State Department of Health the need for additional information and how the delay is in your interest.
Expedited Appeal Process. Action following denial of a request for expedited resolution. Anytime that CONTRACTOR denies a request for an expedited resolution of an appeal, it shall do the following: • Transfer the appeal to the standard timeframe of no longer than forty-five days (45) days from the day the CONTRACTOR receives the appeal with a possible fourteen-day (14) extension; and • Make reasonable efforts to give the enrollee prompt oral notice of the denial, and a written notice within two (2) calendar days.
Expedited Appeal Process. If you believe that your life, health or ability to regain or maintain maximum function could be seriously jeopardized, absent the provision of the service in dispute, let us know right away and we will process your appeal through as an expedited appeal. ElderONE will respond to your appeal as quickly as your health condition requires, but no later 72 hours of receipt of the appeal. The 72 hour time frame may be extended by up to 14 calendar days if you request the extension or if ElderONE justifies to the New York State Department of Health the need for additional information and that this delay is in your best interest. If ▇▇▇▇▇▇▇▇ decides in your favor, we must provide the disputed service as quickly as your health condition requires. If the decision is not fully in your favor, we will provide you with written notice of the denial. The notice will include the specific reason(s) for the denial, the reason(s) why the service would not improve or maintain your overall health, information about your right to appeal the decision, and a description of your external appeal rights.
Expedited Appeal Process. 13.4.1. The Contractor shall establish and maintain an expedited appeal review process for appeals when the Contractor determines, for a request from the enrollee, or the provider indicates, in making the request on the enrollee’s behalf or supporting the enrollee’s request, that taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function (42 CFR 438.410(a)).
13.4.2. The Contractor shall make a decision on the enrollee’s request for expedited appeal and provide notice, as expeditiously as the enrollee’s health condition requires, within three (3) calendar days after the Contractor receives the appeal. The Contractor shall also make reasonable efforts to provide oral notice.
13.4.3. The Contractor shall ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal (42 CFR 438.410(b)).
13.4.4. If the Contractor denies a request for expedited resolution of an appeal, it shall transfer the appeal to the timeframe for standard resolution and make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice (42 CFR 438.410(c)).
13.4.5. The enrollee has a right to file a grievance regarding the Contractors denial of a request for expedited resolution. The Contractor must inform the enrollee of their right to file a grievance in the notice of denial.
Expedited Appeal Process for Claims Involving Urgent Care