Current through Register Vol. 50, No. 9, September 20, 2024
A. Language and Format Requirements. The
notice must be in writing and must meet the language and format requirements of
federal regulations in order to ensure ease of understanding. Notices must also
comply with the standards set by the department relative to language, content,
and format.
B. Content of Notice.
The notice must explain the following:
1. the
adverse benefit determination the MCO or its subcontractor has taken or intends
to take;
2. the reasons for the
adverse benefit determination, including the right of the member to be provided
upon request and free of charge, reasonable access to and copies of all
documents, records, and other information relevant to the member's adverse
benefit determination;
3. the
member's right to file an appeal with the MCO;
4. the member's right to request a state fair
hearing after the MCO's one-level appeal process has been exhausted;
5. the procedures for exercising the rights
specified in this Section;
6. the
circumstances under which expedited resolution is available and the procedure
to request it; and
7. the members
right to have previously authorized services continue pending resolution of the
appeal, the procedure to make such a request, and the circumstances under which
the member may be required to pay the costs of these services.
C. Notice Timeframes. The MCO must
mail the notice within the following timeframes:
1. for termination, suspension, or reduction
of previously authorized Medicaid-covered services, at least 10 days before the
date of action, except as permitted under federal regulations;
2. for denial of payment, at the time of any
action taken that affects the claim; or
3. for standard service authorization
decisions that deny or limit services, as expeditiously as the member's health
condition requires and within 14 calendar days following receipt of the request
for service. A possible extension of up to 14 additional calendar days may be
granted under the following circumstances:
a.
the member, or his/her representative or a provider acting on the members
behalf, requests an extension; or
b. the MCO justifies (to the department upon
request) that there is a need for additional information and that the extension
is in the member's interest.
D. If the MCO extends the timeframe in
accordance with this Section, it must:
1.
give the member written notice of the reason for the decision to extend the
timeframe;
2. inform the member of
the right to file a grievance if he/she disagrees with that decision;
and
3. issue and carry out its
determination as expeditiously as the member's health condition requires, but
no later than the date that the extension expires.
E. For service authorization decisions not
reached within the timeframes specified in this Section, this constitutes a
denial and is thus an adverse action on the date that the timeframes expire.
1. For expedited service authorization
decisions where a provider indicates, or the MCO determines, that following the
standard timeframe could seriously jeopardize the member's life, health, or
ability to attain, maintain, or regain maximum function, the MCO must make an
expedited authorization decision and provide notice as expeditiously as the
member's health condition requires, but no later than 72 hours after receipt of
the request for service.
2. The MCO
may extend the 72-hour time period by up to 14 calendar days if the member or
provider acting on behalf of the member requests an extension, or if the MCO
justifies (to the department upon request) that there is a need for additional
information and that the extension is in the member's
interest.
F. The
department shall conduct random reviews to ensure that member's are receiving
such notices in a timely manner.
1, 2.
Repealed.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
