Proposed Action. 4.14.3.1 All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s Condition or disease. 4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4. 4.14.3.3 The notice of Proposed Action must contain the following: · The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action. · Additional information, if any, that could alter the decision. · The specific reason used as the basis of the action. · The reasons for the Action must have a factual basis and legal/policy basis. · The Member’s right to file an Administrative Review through the Contractor’s internal Grievance System as described in Section 4.14. · The Provider’s right to file a Provider Complaint as described in Section 4.9.7; · The requirement that a Member exhaust the contractor’s internal Administrative Review Process; · The circumstances under which expedited review is available and how to request it; and · The Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member instructions on how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services. 4.14.3.4 The Contractor shall mail the Notice of Proposed Action within the following timeframes:
Appears in 1 contract
Proposed Action. 4.14.3.1 All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s 's Condition or disease.
4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.
4.14.3.3 The notice of Proposed Action must contain the following: · :
4.14.3.3.1 The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action. · .
4.14.3.3.2 Additional information, if any, that could alter the decision. · .
4.14.3.3.3 The specific reason used as the basis of the action. · .
4.14.3.3.4 The reasons for the Action must have a factual basis and legal/policy basis. · .
4.14.3.3.5 The Member’s 's right to file an Administrative Review through the Contractor’s 's internal Grievance System as described in Section 4.14. · .
4.14.3.3.6 The Provider’s 's right to file a Provider Complaint as described in Section 4.9.7; · ;
4.14.3.3.7 The requirement that a Member exhaust the contractor’s 's internal Administrative Review Process; · ;
4.14.3.3.8 The circumstances under which expedited review is available and how to request it; and · and
4.14.3.3.9 The Member’s 's right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member instructions on how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.. Revised 5/19/2008
4.14.3.4 The Contractor shall mail the Notice of Proposed Action within the following timeframes:
4.14.3.4.1 For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions:
4.14.3.4.1.1 The Contractor has factual information confirming the death of a Member.
4.14.3.4.1.2 The Contractor receives a clear written statement signed by the Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.
4.14.3.4.1.3 The Member's whereabouts are unknown and the post office returns Contractor mail directed to the Member indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member's whereabouts become known).
4.14.3.4.1.4 The Member's Provider prescribes a change in the level of medical care.
4.14.3.4.1.5 The date of action will occur in less than ten (days), in accordance with § 483.12(a) (5) (ii), which provides exceptions to the 30 days notice requirements of § 483.12(a) (5) (i).
4.14.3.4.1.6 The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member Fraud and the facts have been verified, if possible, through secondary sources.
4.14.3.4.2 For denial of payment, at the time of any Proposed Action affecting the Claim.
4.14.3.4.3 For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5. Revised 5/19/2008
4.14.3.4.4 If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member written notice of the reasons for the decision to extend Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Member's health requires and no later than the date the extension expires.
4.14.3.4.5 For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.
Appears in 1 contract
Proposed Action. 4.14.3.1 All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s Condition or disease.
4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.
4.14.3.3 The notice of Proposed Action must contain the following: · The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action. · Additional information, if any, that could alter the decision. · The specific reason used as the basis of the action. · The reasons for the Action must have a factual basis and legal/policy basis. · The Member’s right to file an Administrative Review through the Contractor’s internal Grievance System as described in Section 4.14. · The Provider’s right to file a Provider Complaint as described in Section 4.9.7; · The requirement that a Member exhaust the contractor’s internal Administrative Review Process; · The circumstances under which expedited review is available and how to request it; and · The Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member instructions on how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.
4.14.3.4 The Contractor shall mail the Notice of Proposed Action within the following timeframes:
4.14.3.4.1 For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions: · The Contractor has factual information confirming the death of a Member. · The Contractor receives a clear written statement signed by the Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information. · The Member’s whereabouts are unknown and the post office returns Contractor mail directed to the Member indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts become known).
4.14.3.4.2 The Member’s Provider prescribes a change in the level of medical care.
4.14.3.4.3 The date of action will occur in less than ten (days), in accordance with § 483.12(a) (5) (ii), which provides exceptions to the 30 days notice requirements of § 483.12(a) (5) (i).
4.14.3.4.4 The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member Fraud and the facts have been verified, if possible, through secondary sources.
4.14.3.4.5 For denial of payment, at the time of any Proposed Action affecting the Claim.
4.14.3.4.6 For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5.1.
4.14.3.4.7 If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member written notice of the reasons for the decision to extend the timeframe and inform the enrollee of the right to file a Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Member’s health requires and no later than the date the extension expires.
4.14.3.4.8 For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.
Appears in 1 contract
Proposed Action. 4.14.3.1 All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s Condition or disease.
4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.
4.14.3.3 The notice of Proposed Action must contain the following: · :
4.14.3.3.1 The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action. · Additional information, if any, that could alter the decision. · The specific reason used as the basis of the action. · .
4.14.3.3.2 The reasons for the Action must have a factual basis and legal/policy basis. · Action.
4.14.3.3.3 The Member’s right to file an Administrative Review Appeal through the Contractor’s internal Grievance System as described in Section 4.14. · .
4.14.3.3.4 The Provider’s right to file a Provider Complaint as described in Section 4.9.7; · ;
4.14.3.3.5 The requirement that a Member exhaust the contractorContractor’s internal Grievance System and a Provider exhaust the Provider Complaint process prior to requesting a State Administrative Review Process; · Law Hearing;
4.14.3.3.6 The circumstances under which expedited review is available and how to request it; and · and
4.14.3.3.7 The Member’s right to have Benefits continue pending resolution of the Administrative Review Appeal with the ContractorContractor or with the State Administrative Law Hearing, Member instructions on how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.
4.14.3.4 The Contractor shall mail the Notice of Proposed Action within the following timeframes:
4.14.3.4.1 For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions:
i. The Contractor has factual information confirming the death of a Member.
ii. The Contractor receives a clear written statement signed by the Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.
iii. The Member’s whereabouts are unknown and the post office returns Contractor mail directed to the Member indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts become known).
iv. The Member’s Provider prescribes a change in the level of medical care.
v. The date of action will occur in less than ten (10) Calendar Days in accordance with 42 CFR 483.12(a)(5)(ii),
vi. The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member Fraud and the facts have been verified, if possible, through secondary sources.
4.14.3.4.2 For denial of payment, at the time of any Proposed Action affecting the Claim.
4.14.3.4.3 For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5.
4.14.3.4.4 If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member written notice of the reasons for the decision to extend Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Member’s health requires and no later than the date the extension expires.
4.14.3.4.5 For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.
Appears in 1 contract
Proposed Action. 4.14.3.1 All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s Condition or disease.
4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.
4.14.3.3 The notice of Proposed Action must contain the following: · :
4.14.3.3.1 The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action. · .
4.14.3.3.2 Additional information, if any, that could alter the decision. · .
4.14.3.3.3 The specific reason used as the basis of the action. · .
4.14.3.3.4 The reasons for the Action must have a factual basis and legal/policy basis. · .
4.14.3.3.5 The Member’s right to file an Administrative Review through the Contractor’s internal Grievance System as described in Section 4.14. · .
4.14.3.3.6 The Provider’s right to file a Provider Complaint as described in Section 4.9.7; · ;
4.14.3.3.7 The requirement that a Member exhaust the contractor’s internal Administrative Review Process; · ;
4.14.3.3.8 The circumstances under which expedited review is available and how to request it; and · and
4.14.3.3.9 The Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member instructions on how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.
4.14.3.4 The Contractor shall mail the Notice of Proposed Action within the following timeframes:
4.14.3.4.1 For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions:
4.14.3.4.1.1 The Contractor has factual information confirming the death of a Member.
4.14.3.4.1.2 The Contractor receives a clear written statement signed by the Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.
4.14.3.4.1.3 The Member’s whereabouts are unknown and the post office returns Contractor mail directed to the Member indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts become known).
4.14.3.4.1.4 The Member’s Provider prescribes a change in the level of medical care.
4.14.3.4.1.5 The date of action will occur in less than ten (days), in accordance with § 483.12(a) (5) (ii), which provides exceptions to the 30 days notice requirements of § 483.12(a) (5) (i).
4.14.3.4.1.6 The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member Fraud and the facts have been verified, if possible, through secondary sources.
4.14.3.4.2 For denial of payment, at the time of any Proposed Action affecting the Claim.
4.14.3.4.3 For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5.
4.14.3.4.4 If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member written notice of the reasons for the decision to extend Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Member’s health requires and no later than the date the extension expires.
4.14.3.4.5 For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.
Appears in 1 contract
Sources: Contract for Provision of Services (Amerigroup Corp)
Proposed Action. 4.14.3.1 All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s Condition or disease.
4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.
4.14.3.3 The notice of Proposed Action must contain the following: · :
4.14.3.3.1 The Action the Contractor has taken or intends to take, including the service or procedure that is subject to the Action. · Additional information, if any, that could alter the decision. · The specific reason used as the basis of the action. · .
4.14.3.3.2 The reasons for the Action must have a factual basis and legal/policy basis. · Action.
4.14.3.3.3 The Member’s right to file an Administrative Review Appeal through the Contractor’s internal Grievance System as described in Section 4.14. · .
4.14.3.3.4 The Provider’s right to file a Provider Complaint as described in Section 4.9.7; · ;
4.14.3.3.5 The requirement that a Member exhaust the contractorContractor’s internal Grievance System and a Provider exhaust the Provider Complaint process prior to requesting a State Administrative Review Process; · Law Hearing;
4.14.3.3.6 The circumstances under which expedited review is available and how to request it; and · and
4.14.3.3.7 The Member’s right to have Benefits continue pending resolution of the Administrative Review Appeal with the ContractorContractor or with the State Administrative Law Hearing, Member instructions on how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.
4.14.3.4 The Contractor shall mail the Notice of Proposed Action within the following timeframes:
4.14.3.4.1 For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions:
i. The Contractor has factual information confirming the death of a Member.
ii. The Contractor receives a clear written statement signed by the Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.
iii. The Member’s whereabouts are unknown and the post office returns Contractor mail directed to the Member indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts become known).
iv. The Member’s Provider prescribes a change in the level of medical care.
v. The date of action will occur in less than ten (10) Calendar Days in accordance with 42 CFR 483.12(a)(5)(ii).
vi. The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member Fraud and the facts have been verified, if possible, through secondary sources.
4.14.3.4.2 For denial of payment, at the time of any Proposed Action affecting the Claim.
4.14.3.4.3 For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5.
4.14.3.4.4 If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member written notice of the reasons for the decision to extend Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Member’s health requires and no later than the date the extension expires.
4.14.3.4.5 For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.
Appears in 1 contract