Common use of The Grievance Process Clause in Contracts

The Grievance Process. 1. The Grievance process is the Health Plan's procedure for addressing Enrollee Grievances, which are expressions of dissatisfaction about any matter other than Action. 2. An Enrollee may file a Grievance, or a provider (whether a participating Provider or a nonparticipating provider), acting on behalf of the Enrollee and with the Enrollee's written consent, may file a Grievance. 3. The Health Plan must complete the Grievance process in time to permit the Enrollee's disenrollment to be effective in accordance with the time frames specified in 42 CFR 438.56(e)(1). 4. General Health Plan Duties a. The Health Plan must: (1) Resolve each Grievance within State-established time frames not to exceed ninety (90) Calendar Days from the day the Health Plan received the initial Grievance request, be it oral or in writing; (2) Notify the Enrollee, in writing, within ninety (90) Calendar Days of the resolution of the Grievance. The notice of disposition shall include the results and date of the resolution of the Grievance, and for decisions not wholly in the Enrollee's favor, the notice of disposition shall include: (a) Notice of the right to request a Medicaid Fair Hearing if applicable; (b) Information necessary to allow the Enrollee/provider to request a Medicaid Fair Hearing, including the contact information necessary to pursue a Medicaid Fair Hearing (see Section IX.D., below); (3) Provide the Agency with a copy of the written notice of disposition upon request; and (4) Ensure that no punitive action is taken against a provider who files a Grievance on behalf of an Enrollee, or supports an Enrollee's Grievance. b. The Health Plan may extend the Grievance resolution time frame by up to fourteen (14) Calendar Days if the Enrollee requests an extension, or the Health Plan documents that there is a need for additional information and that the delay is in the Enrollee's best interest. (1) If the extension is not requested by the Enrollee, the Health Plan must give the Enrollee written notice of the reason for the delay.

The Grievance Process. 1. The Grievance process is the Health Plan's ’s procedure for addressing Enrollee Grievances, which are expressions of dissatisfaction about any matter other than Action. 2. An Enrollee may file a Grievance, or a provider (whether a participating Provider or a nonparticipating provider), acting on behalf of the Enrollee and with the Enrollee's ’s written consent, may file a Grievance. 3. The Health Plan must complete the Grievance process in time to permit the Enrollee's ’s disenrollment to be effective in accordance with the time frames specified in 42 CFR 438.56(e)(1). 4. General Health Plan Duties a. The Health Plan must: (1) Resolve each Grievance within State-established time frames not to exceed ninety (90) Calendar Days from the day the Health Plan received the initial Grievance request, be it oral or in writing; (2) Notify the Enrollee, in writing, within ninety (90) Calendar Days of the resolution of the Grievance. The notice of disposition shall include the results and date of the resolution of the Grievance, and for decisions not wholly in the Enrollee's ’s favor, the notice of disposition shall include: (a) Notice of the right to request a Medicaid Fair Hearing if applicable; (b) Information necessary to allow the Enrollee/provider to request a Medicaid Fair Hearing, including the contact information necessary to pursue a Medicaid Fair Hearing (see Section IX.D., below); (3) Provide the Agency with a copy of the written notice of disposition upon request; and (4) Ensure that no punitive action is taken against a provider who files a Grievance on behalf of an Enrollee, or supports an Enrollee's ’s Grievance. b. The Health Plan may extend the Grievance resolution time frame by up to fourteen (14) Calendar Days if the Enrollee requests an extension, or the Health Plan documents that there is a need for additional information and that the delay is in the Enrollee's ’s best interest. (1) If the extension is not requested by the Enrollee, the Health Plan must give the Enrollee written notice of the reason for the delay. c. Filing Requirements (1) The Enrollee or provider may file a Grievance within one (1) year after the date of occurrence that initiated the Grievance. (2) The Enrollee or provider may file a Grievance either orally or in writing. An oral request may be followed up with a written request, however the timeframe for resolution begins the date the plan receives the oral request.