Louisiana Administrative Code
Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE
Part I - Administration
Subpart 3 - Managed Care for Physical and Behavioral Health
Chapter 37 - Grievance and Appeal Process
Subchapter A - Member Grievances and Appeals
Section I-3707 - Handling of Member Grievances and Appeals
Universal Citation: LA Admin Code I-3707
Current through Register Vol. 50, No. 9, September 20, 2024
A. In handling grievances and appeals, the MCO must meet the following requirements:
1.
give members any reasonable assistance in completing forms and taking other
procedural steps. This includes, but is not limited to, providing interpreter
services and toll-free telephone numbers that have adequate TTY/TTD and
interpreter capability;
2.
acknowledge receipt of each grievance and appeal;
3. ensure that the individuals who make
decisions on grievances and appeals are individuals who:
a. were not involved in any previous level of
review or decision-making, nor a subordinate of any such individual;
and
b.if deciding on any of the
following issues, are individuals who have the appropriate clinical expertise,
as determined by the department, in treating the member's condition or disease:
i. an appeal of a denial that is based on
lack of medical necessity;
ii. a
grievance regarding denial of expedited resolution of an appeal; or
iii. a grievance or appeal that involves
clinical issues.
B. Special Requirements for Appeals
1. The process for appeals must:
a. provide that oral inquiries seeking to
appeal an action are treated as appeals (to establish the earliest possible
filing date for the appeal) and must be confirmed in writing, unless the member
or the provider requests expedited resolution;
b. provide the member a reasonable
opportunity to present evidence and allegations of fact or law in person as
well as in writing. The MCO must inform the member of the limited time
available for this in the case of expedited resolution;
c. provide the member and his/her
representative an opportunity, before and during the appeals process, to
examine the member's case file, including medical records, any other documents
and records, and any new or additional evidence considered, relied upon, or
generated by the MCO during the appeals process. This information must be
provided free of charge and sufficiently in advance of the resolution timeframe
for appeals; and
d. include, as
parties to the appeal:
i. the member and
his/her representative; or
ii. the
legal representative of a deceased member's estate.
2. The MCOs staff shall be
educated concerning the importance of the grievance and appeal procedures and
the rights of the member and providers.
3. The appropriate individual or body within
the MCO having decision making authority as part of the grievance and appeal
procedures shall be identified.
4.
Failure to Make a Timely Decision
a. Appeals
shall be resolved no later than the stated time frames and all parties shall be
informed of the MCOs decision.
b.
If a determination is not made by the contractual time frames, the member's
request will be deemed to have been exhausted and the member may initiate a
state fair hearing.
5.
The MCO shall inform the member that he/she may seek a state fair hearing if
the member is not satisfied with the MCOs decision in response to an
appeal.
AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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