Common use of Proposed Action Clause in Contracts

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 or P4HB Member’s Condition or disease. 4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member or P4HB 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 or P4HB 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 or P4HB 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 or P4HB Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member or P4HB Member instructions on how to request that Benefits be continued, and the circumstances under which the Member or P4HB 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 or P4HB Member. · The Contractor receives a clear written statement signed by the Member or P4HB 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 post office returns Contractor mail directed to the Member or P4HB Member indicating no forwarding address and the Member’s whereabouts are unknown and (refer to 42 CFR 431.231(d) for procedures if the Member or P4HB Member’s whereabouts become known). · The Member or P4HB Member’s Provider prescribes an immediate change in the level of medical care. 4.14.3.4.2 The date of action will occur in less than ten (days), in accordance with 42 C.F.R. §483.12(a) (5) (ii), which provides exceptions to the 30 days’ notice requirements of 42 C.F.R. § 483.12(a) (5) (i). 4.14.3.4.3 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 or P4HB Member Fraud and the facts have been verified, if possible, through secondary sources.

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 or P4HB Member’s Condition or disease. 4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member or P4HB 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 or P4HB 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 or P4HB 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 or P4HB Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member or P4HB Member instructions on how to request that Benefits be continued, and the circumstances under which the Member or P4HB 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 or P4HB Member. · • The Contractor receives a clear written statement signed by the Member or P4HB 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 post office returns Contractor mail directed to the Member or P4HB Member indicating no forwarding address and the Member’s whereabouts are unknown and (refer to 42 CFR 431.231(d) for procedures if the Member or P4HB Member’s whereabouts become known). · • The Member or P4HB Member’s Provider prescribes an immediate change in the level of medical care. 4.14.3.4.2 The date of action will occur in less than ten (days), in accordance with 42 C.F.R. §483.12(a) (5) (ii), which provides exceptions to the 30 days’ notice requirements of 42 C.F.R. § 483.12(a) (5) (i). 4.14.3.4.3 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 or P4HB Member Fraud and the facts have been verified, if possible, through secondary sources.

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 or P4HB Member’s Condition or disease. 4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member or P4HB 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 or P4HB 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 or P4HB 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 or P4HB Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member or P4HB Member instructions on how to request that Benefits be continued, and the circumstances under which the Member or P4HB 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 or P4HB Member. · • The Contractor receives a clear written statement signed by the Member or P4HB 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 post office returns Contractor mail directed to the Member or P4HB Member indicating no forwarding address and the Member’s whereabouts are unknown and (refer to 42 CFR 431.231(d) for procedures if the Member or P4HB Member’s whereabouts become known). · • The Member or P4HB Member’s Provider prescribes an immediate change in the level of medical care. 4.14.3.4.2 The date of action will occur in less than ten (days), in accordance with 42 C.F.R. §483.12(a) (5) (ii), which provides exceptions to the 30 days’ days notice requirements of 42 C.F.R. § 483.12(a) (5) (i). 4.14.3.4.3 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 or P4HB Member Fraud and the facts have been verified, if possiblepossibl, through secondary sources.

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 or P4HB Member’s Condition or disease. 4.14.3.2 In the event of a Proposed Action, the Contractor shall notify the Member or P4HB 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 or P4HB 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 or P4HB 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 or P4HB Member’s right to have Benefits continue pending resolution of the Administrative Review with the Contractor, Member or P4HB Member instructions on how to request that Benefits be continued, and the circumstances under which the Member or P4HB 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 or P4HB Member. · The Contractor receives a clear written statement signed by the Member or P4HB 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 post office returns Contractor mail directed to the Member or P4HB Member indicating no forwarding address and the Member’s whereabouts are unknown and (refer to 42 CFR 431.231(d) for procedures if the Member or P4HB Member’s whereabouts become known). · The Member or P4HB Member’s Provider prescribes an immediate change in the level of medical care. 4.14.3.4.2 The date of action will occur in less than ten (days), in accordance with 42 C.F.R. §483.12(a) (5) (ii), which provides exceptions to the 30 days’ days notice requirements of 42 C.F.R. § 483.12(a) (5) (i). 4.14.3.4.3 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 or P4HB Member Fraud and the facts have been verified, if possiblepossibl, through secondary sources.