PARTICIPANT At least thirty (30) DAYS prior to the termination of a See description Notification of agreement during the benefit period, the Terminated CONTRACTOR sends written notification, as approved Agreement by the DEPARTMENT, to all PARTICIPANTS who have had services from that in the past twelve (12) months that includes the following information: How to find a new IN-NETWORK , The continuity of care provision as it relates to this situation, and Contact information for questions. PARTICIPANT The CONTRACTOR provides the PARTICIPANT with See description Notification of notice of their grievance rights and a period of one Grievance Rights hundred eighty (180) calendar DAYS to file a grievance after written denial of a BENEFIT or other occurrence of the cause of the grievance along with the Uniform Benefit contractual provision(s) upon which the denial is based. See . PARTICIPANT In the final grievance decision letters, the See description Notification of CONTRACTOR informs PARTICIPANTS of their right to request a DEPARTMENT review of the grievance DEPARTMENT Administrative final decision and their right to request an committee’s HHS-administered federal external review in accordance Review Rights with federal law, using the language approved by the DEPARTMENT. See . 315 Performance Standards and Penalties Performance standards are specific to data from the HEALTH BENEFIT PROGRAM, not general data from the book-of-business. The CONTRACTOR must track performance CONTRACTOR’S using the template provided by the DEPARTMENT. The CONTRACTOR must submit reports and supporting documentation for validation as mutually agreed upon with the DEPARTMENT. The CONTRACTOR shall notify the DEPARTMENT upon realization that a standard will not be met, prior to the deadline. The penalties assessed shall not exceed twenty-five (25%) percent of the total CONTRACTOR’S administrative fee in any given quarter. After implementation, all performance standards will be measured by the DEPARTMENT on a QUARTERLY basis and assessed based on PARTICIPANT counts as of the first calendar DAY of the quarter, as determined by
PARTICIPANT Notification of Terminated Agreement At least thirty (30) DAYS prior to the termination of a agreement during the benefit period, the CONTRACTOR sends written notification, as approved by the DEPARTMENT, to all PARTICIPANTS who have had services from that in the past twelve (12) months that includes the following information: How to find a new IN-NETWORK , The continuity of care provision as it relates to this situation, and Contact information for questions. See description PARTICIPANT Notification of Grievance Rights The CONTRACTOR provides the PARTICIPANT with notice of their grievance rights and a period of one hundred eighty (180) calendar DAYS to file a grievance after written denial of a BENEFIT or other occurrence of the cause of the grievance along with the Uniform Benefit contractual provision(s) upon which the denial is based. See . See description PARTICIPANT Notification of DEPARTMENT Administrative Review Rights In the final grievance decision letters, the CONTRACTOR informs PARTICIPANTS of their right to request a DEPARTMENT review of the grievance committee’s final decision and their right to request an HHS-administered federal external review in accordance with federal law, using the language approved by the DEPARTMENT. See . See description 315 Performance Standards and Penalties Performance standards are specific to data from the HEALTH BENEFIT PROGRAM, not general data from the CONTRACTOR’S book-of-business. The CONTRACTOR must track performance using the template provided by the DEPARTMENT. The CONTRACTOR must submit reports and supporting documentation for validation as mutually agreed upon with the DEPARTMENT. The CONTRACTOR shall notify the DEPARTMENT upon realization that a standard will not be met, prior to the deadline. The penalties assessed shall not exceed twenty-five (25%) percent of the CONTRACTOR’S total administrative fee in any given quarter. After implementation, all performance standards will be measured by the DEPARTMENT on a QUARTERLY basis and assessed based on PARTICIPANT counts as of the first calendar DAY of the quarter, as determined by
Exhibit1_PBP_Agreement_Rev.docx