Current through Register Vol. 50, No. 9, September 20, 2024
A. The MCO
must resolve each grievance and appeal, and provide notice as expeditiously as
the member's health condition requires, within the timeframes established in
this Section. The MCO must provide written notice to all member's who filed a
grievance whether the grievance was filed with the MCO or the
department.
B. Specific Timeframes
1. For standard disposition of a grievance
and notice to the affected parties, the timeframe is established as 30 days, or
the timeframe established by the department, not to exceed 90 days, from the
day the MCO receives the grievance.
2. For standard resolution of an appeal and
notice to the affected parties, the timeframe is established as 30 calendar
days from the day the MCO receives the appeal.
3. For expedited resolution of an appeal and
notice to affected parties, the timeframe is established as 72 hours or as
expeditiously as the members health requires after the MCO receives the
appeal.
C. Extension of
Timeframes
1. The MCO may extend the
timeframes by up to 14 calendar days under the following circumstances:
a. the member requests the extension;
or
b. the MCO shows to the
satisfaction of the department, upon its request, that there is need for
additional information and that the delay is in the member's
interest.
D.
If the MCO extends the timeframes for any extension not requested by the
member, it must give the member written notice of the reason for the
delay.
E. Format of Notice
1. The MCO shall follow the method specified
by the department to notify a member of the disposition of a
grievance.
2. For all appeals, the
MCO must provide written notice of the resolution.
3. For notice of an expedited resolution, the
MCO must provide written notice of the resolution and also make reasonable
efforts to provide oral notice.
F. Content of Notice of Appeal Resolution.
The written notice of the resolution must include, at a minimum, the following
information:
1. the results of the resolution
process and the date it was completed;
2. for appeals not resolved wholly in favor
of the members:
a. the right to request a
state fair hearing and the procedure to make the request;
b. the right to request to receive previously
authorized services during the hearing process and the procedure to make such a
request; and
c. that the member may
be held liable for the cost of those services if the hearing decision upholds
the MCOs action.
G
. Requirements for State Fair Hearings
1. The department shall comply with the
federal regulations governing fair hearings. The MCO shall comply with all of
the requirements as outlined in the contract and department issued
guides.
2. If the member has
exhausted the MCO's one-level appeal procedures, the member may initiate a
state fair hearing within 120 days from the date of the MCO's notice of appeal
resolution.
3. The parties to the
state fair hearing include the MCO as well as the member and his/her
representative or the representative of a deceased member's estate.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
