Current through Register Vol. 43, No. 02, November 27, 2024
(1)
This rule is promulgated pursuant to Section
22-6-153(d) of
the Code of Ala. 1975, to establish a grievance and appeal system consisting of
a grievance process, appeal process, and access to the Medicaid Agency's fair
hearing system (the "grievance system") for enrollees in a regional care
organization or an alternate care organization (hereafter collectively referred
to in this rule as "organization").
(2) For the purposes of this rule an
"enrollee" in an organization shall be construed to mean a Medicaid beneficiary
currently enrolled in an organization, or a provider authorized in writing on a
Medicaid Agency approved form to act on behalf of an enrollee, and any other
person authorized in writing on a Medicaid Agency approved form or by court
order to act as a representative on behalf of an enrollee who has filed a
grievance or appeal pursuant to this rule (all of whom shall be collectively
referred to in this rule as "enrollee").
(3) For the purposes of this rule a
"grievance" means an expression of dissatisfaction by an enrollee about any
matter related to the enrollee's care and treatment by the organization in
accordance with
42 CFR
438.400. A grievance does not include matters
that constitute an "action" under the following subsection 5 or any matter that
may be in litigation.
(4) An
enrollee may submit a grievance orally or in writing to the organization within
5 business days of learning of the basis of the grievance. A grievance may only
be filed with the organization. The organization must acknowledge receipt of
the grievance within 5 business days, consider each enrollee grievance and,
provide notice of the resolution of the grievance as expeditiously as the
enrollee's health condition requires and in any event no more than 30 calendar
days from receipt of the grievance. The organization must assign a person(s)
not directly involved in the matter that is the subject of the grievance to
conduct a reasonable review of the circumstances surrounding the grievance. The
reviewer shall review any relevant parts of the enrollee's case file and
medical records as well as all documents submitted on behalf of the enrollee
and may, as it deems necessary, conduct additional investigation into the
grievance and/or consult with medical or behavioral professionals. The response
to the grievance by the organization shall be in writing and fully explain the
decision reached as to each part of the grievance presented and the reasons for
the decision. Enrollees have no right to appeal an adverse determination of a
grievance. The failure on the part of an organization to act on a grievance as
required by this section shall constitute an action under subsection
5.
(5) For the purposes of this
rule an "action" means action the organization has taken or plans to take that
could result in a material change or limitation to enrollee's care and
treatment including but not limited to the approval or denial of care, adverse
decisions related to billing and payment or bundling matters, and other
decisions related to the provision of health care services offered, made
available or denied to the enrollee by the organization that constitutes an
action under
42 CFR
438.400. For the purposes of this rule "the
provision of health care services" shall include, but not be limited to, the
denial or limited authorization of a claim or requested service, including the
type or level of service; the reduction, suspension, or termination of an
authorized service; the total or partial denial of payment for a service; the
failure to provide services in a timely manner as required by state or federal
law or rules of the Medicaid Agency; the failure of an organization to act
within timeframes established by the Medicaid Agency or within the timeframes
provided in
42 CFR
438.408(b); or in applicable
cases, the denial of an enrollee's request to exercise his or her right to
obtain services outside of the delivery network of the organization. For the
purposes of this rule, an appeal shall be construed to mean the request for
review of an "action."
(6)
(a) In the event the organization takes or
decides to take an action (as defined herein) regarding an enrollee, a written
"notice of action" shall be provided to the enrollee as expeditiously as
possible but whenever possible not less than 10 calendar days before the date
of any proposed action that would involve termination, suspension or reduction
of a previously authorized covered service, unless the delay resulting from
such a notice is reasonably believed to be injurious to enrollee's health and
welfare by enrollee's treating physicians or except as otherwise required by
§438.404(c). The notice shall be sent by mail to enrollee's last known
address and may also be communicated to enrollee by email or facsimile
transmission. All such notices of action must at a minimum, clearly and
thoroughly explain, on forms approved by the Medicaid Agency:
1. The action the organization has taken or
proposes to take and when;
2. The
reasons for the action taken or proposed;
3. The full rights of appeal the enrollee has
to challenge the action under the provisions of this rule and Section
22-6-153(d),
including but not limited to the right to seek an expedited appeal in certain
cases;
4. The procedures an
enrollee must follow to exercise his/her rights to appeal;
5. The enrollee's right to request and
receive a continuation of benefits pending resolution of the appeal, the
process to request continuation of benefits and the circumstance under which
the enrollee may later be required to pay for the services continued during
appeal; and
6. The time by which
all appeals must be filed by the enrollee.
(b) The period of advanced notice is
shortened to five (5) calendar days if probable enrollee fraud has been
verified.
(c) The period of notice
shall be the date of the action for the following:
1. In case of the death of an
enrollee;
2. A signed written
enrollee statement requesting service termination or giving information
requiring termination or reduction of services (where he or she understands
that this must be the result of supplying that information);
3. The enrollee's admission to an institution
where he or she is ineligible for further services;
4. The enrollee's address is unknown and mail
directed to him or her has no forwarding address;
5. The enrollee has been accepted for
Medicaid services by another local jurisdiction; and
6. The enrollee's physician prescribes the
change in the level of medical care.
(d) Pursuant to
42 CFR
438.404(c)(2), when the
notice of action is a denial of payment, the organization shall provide
enrollee written notice on the date of the action.
(e) Pursuant to
42 CFR
438.210(c), the organization
must notify the requesting provider of any decision to deny a service
authorization request or of any decision to authorize a service in amount,
scope or duration that is less than requested. The notice need not be in
writing but must meet the requirements of
42 CFR
438.404.
(7) The enrollee may within 20 calendar days
of receipt of notice of an action file an appeal orally or in writing of the
action before the medical director of the organization, who shall be a primary
care physician. The enrollee shall state in the notice of appeal whether oral
hearing is requested. An oral notice of appeal must be confirmed in writing
within 3 calendar days.
(a) The medical
director must send the enrollee notice of receipt of the appeal within 3
calendar days. The acknowledgment shall state when the enrollee's appeal will
be decided, which, except as otherwise provided herein, shall be no later than
10 calendar days from the date of filing of the notice of appeal. In the event
enrollee requests an oral hearing, that hearing shall be no later than 20
calendar days of filing the notice of appeal.
(b) The organization shall immediately
provide the medical director all relevant parts of enrollee's case file and
medical records and any information submitted by enrollee.
(c) Within 5 calendar days of filing the
notice of appeal, enrollee shall submit to the medical director all written
materials the enrollee would like to be considered. The medical director shall
consider all relevant parts of the enrollee's case file and medical records as
well as any additional material submitted on behalf of the enrollee. If oral
hearing has been requested in the notice of appeal, the enrollee shall have an
opportunity to present evidence, allegations of fact and law, as well as
arguments, in person, writing or by telephone, at the election of
enrollee.
(d) The rules of evidence
shall not apply.
(e) The medical
director's decision shall be binding on the organization and must be provided
to enrollee orally or in writing within 1 calendar day of resolution of
enrollee's appeal. Oral notices of the resolution must be confirmed in writing
within 2 additional calendar days on a form approved by the Medicaid Agency.
The written notice of the decision shall state in reasonable detail the basis
for the decision.
(8) If
the enrollee is dissatisfied with the decision of the medical director, the
enrollee may within 10 calendar days of notification of the decision file a
written or oral notice of appeal with the organization to be heard by a peer
review committee of the organization. An oral appeal must be confirmed in
writing within 5 calendar days.
(a) The peer
review committee shall be composed of at least three physicians who have the
same specialty as the ordering or prescribing physician and who work within the
region in which the services or matter is at issue. If three physicians cannot
be found to serve who work within the region served by the organization, then
the positions may be filled by physicians of the same specialty who work
outside of the region.
(b) The
organization shall send enrollee acknowledgment of receipt of the appeal within
3 calendar days of receipt of the notice. The acknowledgment shall state when
the enrollee's appeal will be heard, which shall be no less than 7 and no more
than 21 calendar days of the filing of the notice of appeal.
(c) The organization shall provide the peer
review committee all relevant parts of enrollee's case file and medical records
and all other information submitted by enrollee.
(d) The peer review committee shall consider
all relevant parts of the enrollee's case file and medical records along with
any additional material submitted on behalf of the enrollee.
(e) The enrollee shall have the right to
present arguments, evidence, and allegations of fact or law in person, writing
or by telephone.
(f) The rules of
evidence shall not apply.
(g) The
peer review committee's decision shall be sent to enrollee within 14 calendar
days of the hearing on appeal on a form approved by the Medicaid Agency and be
binding on the organization.
(h) A
peer review committee formed pursuant to Section
22-6-153(d) and
this rule shall be separate and distinct from a peer review committee created
pursuant to Administrative Rule
560-X-2-.01 et seq. and not
subject to the provisions of that rule.
(9) If the enrollee is dissatisfied with the
decision of the peer review committee, the enrollee may within 20 calendar days
of notice of the decision submit a notice of appeal to the Medicaid Agency on a
form approved by the Medicaid Agency. The enrollee shall also submit a copy of
the notice of appeal to the organization on the same date. Timely oral requests
shall be permitted so long as the oral request is reduced to writing within 48
hours. In the event an enrollee files a notice of appeal with the organization
instead of the Medicaid Agency, the organization shall forward such request to
the Medicaid Agency within two business days of receipt.
(a) The Medicaid Agency shall within 10
calendar days of receipt of the notice of the appeal provide the enrollee
written notice of such receipt and of the date and time the appeal will be
heard by the Medicaid Agency. The appeal shall be heard no sooner than 10
calendar days or any longer than 30 calendar days from the date of the notice
setting the date and time of appeal. Hearings may be continued for up to 14
calendar days at the request of the enrollee, or for good cause shown, at the
request of the regional care organization. For extensions not requested by the
enrollee, the organization must provide the enrollee prompt written notice of
the reason for the delay and the extension must be in the enrollee's best
interest.
(b) The Medicaid Agency
shall request the following information from the organization which must be
provided within 14 calendar days from the filing of the notice of appeal:
1. A copy of the relevant parts of enrollee's
case file and medical records; and
2. All documents considered by or presented
to the medical director and the peer review committee and the decisions
rendered by each.
(c)
The enrollee shall be entitled to review all such information before and during
the hearing on enrollee's appeal.
(d) The enrollee shall be afforded a full
evidentiary hearing in the region in which the enrollee resides.
(e) The parties to the appeal shall be the
regional care organization and the enrollee. The enrollee may represent
himself/herself before the Medicaid Agency or have someone else appear on
enrollee's behalf in person, by telephone or in writing at the election of the
enrollee and be provided a reasonable opportunity to present arguments,
evidence and allegations of fact or law.
(f) A record must be made of the hearing and
the organization shall be responsible for the cost.
(g) The Medicaid Agency will send to the
enrollee and the provider a written finding of the decision within 15 calendar
days of the hearing before the Medicaid Agency stating with specificity the
basis for the decision as well as all matters considered in reaching the
decision which shall be binding upon the regional care organization.
(10) If the enrollee is
dissatisfied with the decision rendered by the Medicaid Agency, enrollee may
file an appeal to the circuit court in the county in which the enrollee
resides, or the county in which the provider provides the services at issue to
the enrollee. The enrollee must file the appeal in circuit court by no later
than 30 calendar days after receipt of the decision rendered in connection with
the appeal to the Medicaid Agency.
(11) Each organization must have written
policies and procedures approved by the Medicaid Agency that clearly and fully
explain an enrollee's right to file grievances and appeals of actions, as well
as forms approved by the Medicaid Agency for filing grievances and appeals
pursuant to sections (7) and (8) of this rule. Any material changes to such
policies and procedures must be approved by the Medicaid Agency and copies
provided to enrollees and providers in writing at least 30 calendar days prior
to implementation.
(a) All policies,
procedures and forms required herein shall meet the requirements of
42 CFR
§438.10 and Medicaid Agency
Administrative Rule No.
560-X-62-.21. The rights of
enrollees to file grievances and appeals, the process to do so, and the
required forms shall be posted on the website of the organization and provided
to the enrollee within 60 days of enrollment. Such documents shall also be
provided to providers when provider contracts are entered into.
(b) Each organization must maintain a toll
free number for enrollees to use to orally submit a grievance or notice of
appeal. The toll free number must be available during normal business
hours.
(c) The organization must
cooperate with the enrollee and provide reasonable assistance as needed to
explain and complete forms and take other procedural steps related to the
filing of grievances and appeals, including but not limited to providing free
interpreter services.
(d) At each
stage of the appeals process the organization, or the Medicaid Agency in the
event of an appeal pursuant to Section 9 hereof, shall:
1. Timely acknowledge in writing receipt of
the notice of appeal and state the date, time and process by which the appeal
is to be heard and decided;
2.
Advise enrollee or his/her provider or duly appointed representative of the
enrollee's rights on appeals including the right to examine the enrollee's
file, medical records and all other information considered or submitted by the
organization; and
3. Advise
enrollee of the right to request benefits while the appeal is pending and that
the enrollee may in such case be held liable for the cost of those benefits if
the appeal is not decided in favor of enrollee.
(e) The organization may not discourage any
enrollee from using any aspect of the grievance system set forth in this rule
nor encourage the withdrawal of a grievance, appeal or hearing request filed
pursuant to this rule. The organization may not use the filing or resolution of
a grievance, appeal of an action or hearing request as a reason to retaliate
against the enrollee or provider or as a basis to seek disenrollment of the
enrollee. The right of an enrollee to file a grievance or appeal and the rights
of an enrollee during the grievance and appeal process shall be fully set forth
in the Provider Manual and Enrollee Handbook supplied to all providers and
enrollees by the organization.
(12) Each grievance and appeal submitted
pursuant to this rule must be appropriately considered and timely resolved in
accordance with the following:
(a) The
organization shall ensure that persons making decisions in connection with any
grievance or appeal were not involved in any previous level of review or
decision-making regarding the matters at issue. The organization shall ensure
that appropriate healthcare professionals participate in all decisions in which
(i) the grievance or appeal involves clinical issues; (ii) the appeal is of a
denial of a request based on lack of medical necessity, or (iii) a grievance is
received regarding denial of a request for an expedited appeal.
(b) All decisions rendered as part of any
grievance or appeal filed on behalf of an enrollee shall be in writing, clearly
state the decision reached and fully explain the reasons for the decision and
documents and criteria considered in rendering the decision.
(c) The organization shall, if requested by
the enrollee, provide reasonable assistance to help the enrollee understand the
decision rendered and if necessary provide an interpreter to assist the
enrollee.
(d) At each level of the
grievance and appeal process set forth herein in which a decision is rendered
that is adverse to enrollee, the enrollee shall be advised in writing by the
organization (or by the Alabama Medicaid Agency in the event of an appeal
pursuant to section 9 of this rule) of any rights of appeal provided the
enrollee pursuant to Section
22-6-153(d) and
under this rule. All such notices shall comply with the requirements of
42 CFR §438.10(c)
and (d) and Rule No.
560-X-62-.21.
(e) The organization must provide written
notice of disposition of the appeal, which notice must include:
1. The results of and date of the resolution
of the appeal.
2. For decisions not
wholly in the enrollee's favor:
(i) The right
to request further appeal;
(ii) How
to request further appeal;
(iii)
The right to continue to receive benefits pending an appeal;
(iv) How to request the continuation of
benefits; and
(v) If the action
taken by the organization is upheld on appeal, the enrollee may be liable for
the cost of any continued benefits.
(13) Consistent with rules promulgated by the
Medicaid Agency and otherwise required by law, the enrollee's right to
confidentiality shall be maintained as much as practical through each step of
the grievance and appeal system taking into consideration the need for
disclosure of medical and other information necessary to resolve enrollee's
grievance or appeal, to determine payments or benefits that may be due and/or
to evaluate quality of care by the organization or the effectiveness of the
grievance system established by the organization. By participating in the
grievance system provided for in this rule the enrollee will be deemed to have
consented to the release of his/her medical records to the extent necessary in
order to act upon enrollee's grievance or appeal and shall execute any
necessary releases for such disclosure.
(14) Notwithstanding anything herein to the
contrary, an enrollee shall have the right to request an expedited appeal to
the organization that would not follow the standard time for appeals otherwise
set forth in this rule, if following the standard time for appeal could
reasonably be expected to seriously jeopardize the enrollee's life or health or
the ability to attain, maintain or regain maximum function. The request may be
filed orally or in writing after which no additional enrollee follow-up is
required.
(a) When a request for expedited
appeal is received the enrollee must be advised within 2 business days of
receipt of the request whether such request is accepted or denied.
(b) If the expedited appeal is accepted, the
enrollee must be advised within 2 business days of receipt of the request of
the limited time available in such case for the enrollee to present evidence,
present or question witnesses, present allegations of fact or law and to appear
in person, writing or by telephone.
(c) In the case of an expedited appeal
pursuant to this section an enrollee shall be advised of the decision on
enrollee's appeal orally or in writing within 3 business days of receipt of the
request for expedited appeal. Regardless of any written notice, reasonable
efforts must be made to provide oral notice within 3 business days. Written
confirmation of any oral notice shall be sent within an additional 2 business
days.
(d) If the decision is made
to deny an expedited appeal the enrollee shall be advised orally within
twenty-four hours and also in writing within 2 business days of the request
after which the standard review and appeals process outlined in this rule shall
apply.
(e) The expedited appeal
process may be extended by up to 14 calendar days if requested by the enrollee
or if the organization determines that there is need for additional information
and that the delay is in the interest of the enrollee.
(f) If the extension requested by the
organization is granted, the enrollee must be promptly notified in writing of
the extension and the reason for the extension.
(g) The organization must ensure that
punitive action by the organization is not taken against an enrollee or
provider who requests an expedited resolution.
(15)
(a)
During each appeal provided for herein, the organization must
continue the enrollee's covered benefits if:
1. the enrollee files the notice of appeal
timely;
2. the appeal involves the
termination, suspension, or reduction of a previously authorized course of
treatment;
3 the services were ordered by an authorized provider;
4. the original period covered by
the original authorization has not expired; and
5. the enrollee requests extension of
benefits.
(b) If, at the
enrollee's request, the organization continues or reinstates the enrollee's
benefits while the appeal is pending, the benefits must be continued until one
of following occurs:
1. the enrollee
withdraws the appeal;
2. 10
calendar days pass after the organization mails the notice, providing the
resolution of the appeal against the enrollee, unless the enrollee, within the
10 calendar day timeframe, has requested an appeal and has requested a
continuation of benefits until that decision is reached;
3. a State fair hearing Officer issues a
hearing decision adverse to the enrollee; and
4. the time period or service limits of a
previously authorized service has been met.
(c) If the final resolution of the appeal is
adverse to the enrollee, that is, upholds the organization's action, the
organization may recover from the enrollee the cost of the services furnished
to the enrollee while the appeal is pending, to the extent that they were
furnished solely because of the requirements of this section, and in accordance
with the policy set forth in 42 CFR
431.230(b).
(d) Pursuant to
42 CFR
438.424(a), if services were
not furnished to the enrollee while the appeal was pending and the decision to
deny, limit or delay services is reversed, the organization must authorize or
provide the disputed services promptly, and as expeditiously as the enrollee's
health condition requires.
(e)
Pursuant to
42 CFR
438.424(b), the organization
must pay for disputed services in accordance with State policy and regulations
if the decision of the organization to deny authorization of services is
reversed and the enrollee received the disputed services while the appeal was
pending.
(16) The
regional care organization shall maintain a grievance log and copies of all
grievances and appeals filed by an enrollee pursuant to this rule, as well as
all decisions rendered in response, for at least 7 years.
(a) The organization shall review the
grievance log for completeness and accuracy regularly, but at least quarterly,
and monitor the outcomes of such grievances and appeals as part of its quality
assurance responsibility. The organization's grievance log shall set forth at a
minimum the enrollee's name, the date and a description of each grievance and
matter appealed; the basis for each grievance and appeal; the enrollee's
provider for the service at issue, if any; whether continuation of benefits
were requested and provided in each instance; the total number of grievances
and appeals; the dates responses to the grievance or appeal were provided to
the enrollee; the date of decision by the organization; and the outcomes of the
grievance and appeals.
(b) The
organization shall file a report at least annually with the Medicaid Agency
that fairly and accurately summarizes the information required to be set forth
on the grievance log.
(c) The
Medicaid Agency shall be entitled to review all documents in the possession of
the organization related to such grievances and appeals as a means of
monitoring quality of care and the effectiveness of the policies and procedures
of the organization in responding to enrollee grievances and appeals.
(17) Notwithstanding any
provisions of this rule to the contrary, an organization shall be governed by
grievance system regulations which may be found in their entirety in 42 CFR
Section 438 Subpart F which are hereby incorporated by reference and made a
part of this rule as if set out in full and all provisions thereof are adopted
as rules of the Medicaid Agency. In addition, the Medicaid Agency may impose
additional requirements for the grievance and appeal system in the risk
contract executed with any organization.
(18) Should the Medicaid Agency reasonably
conclude from the information provided that an organization has not
established, maintained and enforced a grievance system that satisfies the
provisions of this rule and Section
22-6-153(d), the
Medicaid Agency shall require the organization to immediately take appropriate
corrective action? Failure to take appropriate corrective action after a
reasonable opportunity to cure can lead to action brought by the Medicaid
Agency against the organization, including but not limited to suspension or
termination of its certificate as a regional care organization.
(19) In the event of any conflict or
discrepancy between the provisions of this rule and the hearing rules set forth
in Medicaid Administrative Rules
560-X-3-.01 through
560-X-3-.07, this rule shall
control and the conflicting provisions of the other stated rules shall not
apply.
Author: Sharon Weaver, Administrator,
Administrative Procedures Office.
Statutory Authority: Code of Ala. 1975,
§§
22-6-150 et seq., 42 C.F.R. Part
438, 42 C.F.R. Part 431.