(2) The appeal involves the termination, suspension, or reduction of previously authorized
(3) The services were ordered by an authorized provider;
(4) The period covered by the original authorization has not expired; and
(5) The enrollee timely files for continuation of benefits.
(c) Duration of continued or reinstated benefits. If, at the enrollee's request, the MCO, PIHP, or PAHP continues or reinstates the
enrollee's benefits while the appeal or state fair hearing is pending, the benefits
must be continued until one of following occurs:
(1) The enrollee withdraws the appeal or request for state fair hearing.
(2) The enrollee fails to request a state fair hearing and continuation of benefits within
10 calendar days after the MCO, PIHP, or PAHP sends the notice of an adverse resolution
to the enrollee's appeal under § 438.408(d)(2).
(3) A State fair hearing office issues a hearing decision adverse to the enrollee.
(d) Enrollee responsibility for services furnished while the appeal or state fair hearing
is pending. If the final resolution of the appeal or state fair hearing is adverse to the enrollee,
that is, upholds the MCO's, PIHP's, or PAHP's adverse benefit determination, the MCO,
PIHP, or PAHP may, consistent with the state's usual policy on recoveries under § 431.230(b) of this chapter and as specified in the MCO's, PIHP's, or PAHP's contract, recover
the cost of services furnished to the enrollee while the appeal and state fair hearing
was pending, to the extent that they were furnished solely because of the requirements
of this section.
FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature or via Westlaw before relying on it for your legal needs.
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