Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This amendment updates the telephone number for Anthem
expedited appeals and the mailing address and website for external review requests.
EMERGENCY STATEMENT: This emergency amendment must be in place by
January 1, 2024, in accordance with the new plan year. Therefore, this emergency amendment is necessary to
serve a compelling governmental interest of protecting members (public entity employee members, retirees, and
their families) enrolled in the Missouri Consolidated Health Care Plan (MCHCP) from the unintended
consequences of confusion regarding eligibility or availability of benefits and will allow members to take
advantage of opportunities for reduced premiums for more affordable options without which they may forego
coverage. Further, it clarifies member eligibility and responsibility for various types of eligible charges,
beginning with the first day of coverage for the new plan year. It may also help ensure that inappropriate
claims are not made against the state and help protect the MCHCP and its members from being subjected to
unexpected and significant financial liability and/or litigation. It is imperative that this amendment be
filed as an emergency amendment to maintain the integrity of the current health care plan. This emergency
amendment fulfills the compelling governmental interest of offering access to more convenient and affordable
medical services to public entity employee members, retirees, and their families as one (1) method of
protecting the MCHCP trust fund from more costly expenses. This emergency amendment reflects changes made to
the plan by the Missouri Consolidated Health Care Plan Board of Trustees. A proposed amendment, which covers
the same material, is published in this issue of the Missouri Register. This emergency amendment complies
with the protections extended by the Missouri and United States Constitutions and limits its scope to the
circumstances creating the emergency. The MCHCP follows procedures best calculated to assure fairness to all
interested persons and parties under the circumstances. This emergency amendment was filed October 27, 2023
becomes effective January 1, 2024 and expires June 28, 2024.
(1) Claims Submissions and Initial Benefit Determinations.
(A) Members shall use the claims and administration procedures established
by the vendor administering the particular service for which coverage, authorization, or payment is
sought.
(B) Medical and pharmacy service claims are divided into
three (3) types: pre-service, post-service, and concurrent claims.
1.
Pre-service claims are requests for approval that the plan or vendor requires a member to obtain before
getting medical care or filling a prescription, such as prior authorization or a decision whether a
treatment, procedure, or medication is medically necessary.
A. Pre-service
claims must be decided within a reasonable period of time appropriate to the medical circumstances, but no
later than twenty (20) business days from the date the vendor receives the claim. The vendor may extend the
time period up to an additional thirty (30) days if, for reasons beyond the vendor's control, the decision
cannot be made within the first twenty (20) days. The vendor must notify the member prior to the expiration
of the first twenty-(20-) day period, explain the reason for the delay, and request any additional
information. If more information is requested, the member has at least forty-five (45) days to provide the
information to the vendor. The vendor then must decide the claim no later than thirty (30) days after the
additional information is supplied or after the period of time allowed to supply it ends, whichever is
first.
B. Urgent care claims are a special type of pre-service
claim that require a quicker decision because waiting the standard time could seriously jeopardize the
member's life, health, or ability to regain maximum function. A request for an urgent care claim may be
submitted verbally or in writing and will be decided within seventy-two (72) hours. Written confirmation of
the decision will be sent by the vendor within three (3) business days.
2. Post-service claims are all other claims for services including claims
after medical or pharmacy services have been provided, such as requests for reimbursement or payment of the
costs for the services provided.
A. Post-service claims must be decided
within a reasonable period of time, but not later than twenty (20) business days after the vendor receives
the claim. If, because of reasons beyond the vendor's control, more time is needed to review the claim, the
vendor may extend the time period up to an additional thirty (30) days. The vendor must notify the member
prior to the expiration of the first twenty (20-) day period, explain the reason for the delay, and request
any additional information. If more information is requested, the member has at least forty-five (45) days to
provide the information to the vendor. The vendor then must decide the claim no later than thirty (30) days
after the additional information is supplied or after the period of time allowed to supply it ends, whichever
is first.
3. Concurrent claims are claims related to an
ongoing course of previously approved treatment. If the plan or vendor has approved an ongoing course of
treatment to be provided over a period of time or number of treatments, any reduction or termination of the
course of treatment will be treated as a benefit denial. The plan or vendor will notify a member in writing
prior to reducing or ending a previously approved course of treatment in sufficient time to allow the member,
or the member's provider, to appeal and obtain a determination before the benefit is reduced or
terminated.
(C) Claims incurred should be furnished to
the vendor by the provider or the member as soon as reasonably possible. Claims filed more than one (1) year
after charges are incurred will not be honored. All claims are reviewed and/or investigated by the vendor
before they are paid.
(D) If a member, a provider, or authorized
representative on behalf of a member, submits a request for coverage or a claim for services that is denied
in whole or in part, the member will receive an initial denial notice within the timeframes described in this
rule that will include the following information:
1. The reasons for the
denial;
2. Reference to the plan provision, regulation, statute,
clinical criteria, or guideline on which the denial was based, with information as to how the member can
obtain a copy of the provision, regulation, statute, clinical criteria, or guideline free of
charge;
3. A description of any documentation or information that
is necessary for the member to provide if documentation or information is missing and an explanation as to
why the documentation or information is needed, if applicable; and
4. Information as to steps the member can take to submit an appeal of the
denial.
(2) General Appeal Provisions.
(A) All individuals seeking review or appeal of a decision of the plan,
plan administrator, claims administrator, or any vendor shall follow the procedures applicable to the type of
decision appealed as set forth in this rule.
(B) All appeals must
be submitted in writing to the appropriate reviewer as established in this rule by the member, the individual
seeking review, or his/her authorized representative.
(C) Unless
specifically provided otherwise in this rule, all appeals to the plan, plan administrator, claims
administrator, or applicable vendor must be made, initiated in writing, within one hundred eighty (180) days
of issuance of the denial or notice which gave rise to the appeal.
(3) Appeal Process for Medical and Pharmacy Determinations.
(A) Definitions. Notwithstanding any other rule in this chapter to the
contrary, for purposes of a member's right to appeal any adverse benefit determination made by the plan, the
plan administrator, a claims administrator, or a medical or pharmacy benefit vendor, relating to the
provision of health care benefits, other than those provided in connection with the plan's dental or vision
benefit offering, the following definitions apply:
1. Adverse benefit
determination. An adverse benefit determination means any of the following:
A. A denial, reduction, or termination of, or a failure to provide or make
payment (in whole or in part) for a benefit, including any denial, reduction, termination, or failure to
provide or make payment that is based on a determination of an individual's eligibility to participate in the
plan;
B. A denial, reduction, or termination of, or a failure to
provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization
review, as well as a failure to cover an item or service for which benefits are otherwise provided because it
is determined to be experimental or investigational or not medically necessary or appropriate; or
C. Any rescission of coverage after an individual has been covered under
the plan;
2. Appeal (or internal appeal). An appeal or
internal appeal means review by the plan, the plan administrator, a claims administrator, or a medical or
pharmacy benefit vendor of an adverse benefit determination;
3.
Claimant. Claimant means an individual who makes a claim under this subsection. For purposes of this
subsection, references to claimant include a claimant's authorized representative;
4. External review. The United States Department of Health and Human
Services (HHS) conducts external reviews for adverse benefit determinations regarding medical and pharmacy
benefits administered by Anthem and Express Scripts, Inc. that involve medical judgment (including, but not
limited to, those based on medical necessity, appropriateness, health care setting, level of care, or
effectiveness of a covered benefit; or a determination that a treatment is experimental or investigational)
and a rescission of coverage (regardless of whether or not the rescission has any effect on any particular
benefit at that time);
5. Final internal adverse benefit
determination. A final internal adverse benefit determination means an adverse benefit determination that has
been upheld by the plan, the plan administrator, a claims administrator, or a medical or pharmacy benefit
vendor at the completion of the internal appeals process under this subsection, or an adverse benefit
determination with respect to which the internal appeals process has been deemed exhausted by application of
applicable state or federal law;
6. Final external review
decision. A final external review decision means a determination rendered under the external review process
at the conclusion of an external review; and
7. Rescission. A
rescission means a termination or discontinuance of medical or pharmacy coverage that has retroactive effect,
except that a termination or discontinuance of coverage is not a rescission if-
A. The termination or discontinuance of coverage has only a prospective
effect; or
B. The termination or discontinuance of coverage is
effective retroactively to the extent it is attributable to a failure to timely pay required premiums or
contributions towards the cost of coverage.
(B) Internal Appeals.
1. Eligibility,
termination for failure to pay, or rescission. Adverse benefit determinations denying or terminating an
individual's coverage under the plan based on a determination of the individual's eligibility to participate
in the plan or the failure to pay premiums, or any rescission of coverage based on fraud or intentional
misrepresentation of a member or authorized representative of a member are appealable exclusively to the
Missouri Consolidated Health Care Plan (MCHCP) Board of Trustees (board).
A.
The internal review process for appeals relating to eligibility, termination for failure to pay, or
rescission shall consist of one (1) level of review by the board.
B. Adverse benefit determination appeals to the board must identify the
eligibility, termination, or rescission decision being appealed and the reason the claimant believes the
MCHCP staff decision should be overturned. The member should include with his/her appeal any information or
documentation to support his/her appeal request.
C. The appeal
will be reviewed by the board in a meeting closed pursuant to section 610.021, RSMo, and the appeal will be
responded to in writing to the claimant within sixty (60) days from the date the board received the written
appeal.
D. Determinations made by the board constitute final
internal adverse benefit determinations and are not eligible for external review, except as specifically
provided in 22 CSR 10-3.075(4)(A) 4.
2. Medical and
pharmacy services. Members may request internal review of any adverse benefit determination relating to
urgent care, pre-service claims, and post-service claims made by the plan's medical and pharmacy vendors.
A. Appeals of adverse benefit determinations shall be submitted in writing
to the vendor that issued the original determination giving rise to the appeal at the applicable address set
forth in this rule.
B. The internal review process for adverse
benefit determinations relating to medical services consists of two (2) levels of internal review provided by
the medical vendor that issued the adverse benefit determination.
(I) First
level appeals must identify the decision being appealed and the reason the member believes the original claim
decision should be overturned. The member should include with his/her appeal any additional information or
documentation to support the reason the original claim decision should be overturned.
(II) First level appeals will be reviewed by the vendor by someone who was
not involved in the original decision and will consult with a qualified medical professional if a medical
judgment is involved. First level medical appeals will be decided within twenty (20) business days from the
date the vendor received the first level appeal request.
(a) If, because of
reasons beyond the vendor's control, more time is needed to review the appeal, the vendor may extend the time
period up to an additional thirty (30) days. The vendor must notify the member prior to the expiration of the
first twenty- (20-) day period, explain the reason for the delay, and request any additional information. If
more information is requested, the member has at least forty-five (45) days to provide the information to the
vendor. The vendor then must decide the claim no later than thirty (30) days after the additional information
is supplied or after the period of time allowed to supply it ends, whichever is first. Written confirmation
of the decision will be sent by the vendor within fifteen (15) business days.
(III) An expedited appeal of an adverse benefit determination may be
requested when a decision is related to a pre-service claim for urgent care. Expedited appeals will be
reviewed by the vendor by someone who was not involved in the original decision and will consult with a
qualified medical professional if a medical judgment is involved. Expedited appeals will be responded to
within seventy-two (72) hours after receiving a request for an expedited review with written confirmation of
the decision to the member within three (3) business days of providing notification of the
determination.
(IV) Second level appeals must be submitted in
writing within sixty (60) days of the date of the first level appeal decision letter that upholds the
original adverse benefit determination. Second level appeals should include any additional information or
documentation to support the reason the member believes the first level appeal decision should be overturned.
Second level appeals will be reviewed by the vendor by someone who was not involved in the original decision
or first level appeal and will include consultation with a qualified medical professional if a medical
judgment is involved. Second level medical appeals will be decided within twenty (20) days for post-service
claims and within fifteen (15) days for pre-service claims from the date the vendor received the second level
appeal request.
(a) If, because of reasons beyond the vendor's control, more
time is needed to review the appeal, the vendor may extend the time period up to an additional thirty (30)
days. The vendor must notify the member prior to the expiration of the first twenty- (20-) day period,
explain the reason for the delay, and request any additional information. If more information is requested,
the member has at least forty-five (45) days to provide the information to the vendor. The vendor then must
decide the claim no later than thirty (30) days after the additional information is supplied or after the
period of time allowed to supply it ends, whichever is first. Written confirmation of the decision will be
sent by the vendor within fifteen (15) business days.
(V) For members with medical coverage through Anthem-
(a) First and second level pre-service, first and second level
post-service, and concurrent claim appeals must be submitted in writing to-
Anthem Blue Cross and Blue Shield
Attn: Grievance Department
PO Box 105568
Atlanta, Georgia 30348-5568
or by fax to (888) 859-3046
(b) Expedited appeals may be submitted by calling (844) 516-0248 or by
submitting a written fax to (800) 368-3238.
C. The internal review process for adverse benefit determinations relating
to pharmacy and the Pharmacy LockIn Program consists of one (1) level of internal review provided by the
pharmacy vendor.
(I) Pharmacy appeals. Pharmacy appeals and Pharmacy
Lock-In Program appeals must identify the matter being appealed and should include the member's (and
dependent's, if applicable) name, the date the member attempted to fill the prescription, the prescribing
physician's name, the drug name and quantity, the cost of the prescription, if applicable, and any applicable
reason(s) relevant to the appeal including: the reason(s) the member believes the claim should be paid, the
reason(s) the member believes s/he should not be included in the Pharmacy Lock-In Program, and any other
written documentation to support the member's belief that the original decision should be
overturned.
(II) All pharmacy appeals must be submitted in
writing to-
Express Scripts
Attn: Clinical Appeals Department
PO Box 66588
St. Louis, MO 63116-6588
or by fax to (877) 852-4070
(III) All Pharmacy Lock-In Program appeals must be submitted in writing to-
Express Scripts
Drug Utilization Review Program
Mail Stop HQ3W03
One Express Way
St. Louis, MO 63121
(IV) Pharmacy appeals will be reviewed by someone who was not involved in
the original decision and the reviewer will consult with a qualified medical professional if a medical
judgment is involved. Pharmacy appeals will be responded to in writing to the member within sixty (60) days
for post-service claims and thirty (30) days for pre-service claims from the date the vendor received the
appeal request.
(V) The Pharmacy Benefit Manager will respond to
Pharmacy Lock-In Program appeals in writing to the member within thirty (30) days from the date the Pharmacy
Benefit Manager received the appeal request.
D. Members
may seek external review only after they have exhausted all applicable levels of internal review or received
a final internal adverse benefit determination.
(I) A claimant or
authorized representative may file a written request for an external review within four (4) months after the
date of receipt of a final internal adverse benefit determination.
(II) The claimant can submit an external review request in writing to-
MAXIMUS Federal Services
Federal External Review Process (FERP)
3750 Monroe Ave., Suite 705
Pittsford, NY 14534
or by fax to (888) 866-6190
or to request a review online at
externalappeal.cms.gov
(III) The claimant may call the toll-free number (888) 866-6205 with any
questions or concerns during the external review process and can submit additional written comments to the
external reviewer at the mailing address above.
(IV) The external
review decision will be made as expeditiously as possible and within forty-five (45) days after receipt of
the request for the external review.
(V) A claimant may make a
written or oral request for an expedited external review if the adverse benefit determination involves a
medical condition of the claimant for which the time frame for completion of a standard external review would
seriously jeopardize the life or health of the claimant; or would jeopardize the claimant's ability to regain
maximum function; or if the final internal adverse benefit determination involves an admission, availability
of care, continued stay, or health care item or service for which the claimant received services, but has not
been discharged from a facility.
3. For all
internal appeals of adverse benefit determinations, the plan or the vendor reviewing the appeal will provide
the member, free of charge, with any new or additional evidence or rationale considered, relied upon, or
generated by the plan or the vendor in connection with reviewing the claim or the appeal and will give the
member an opportunity to respond to such new evidence or rationale before issuing a final internal adverse
determination.
(4) Except as otherwise
expressly provided in this rule, appeals of adverse determinations made by MCHCP may be appealed to the board
by sending or uploading the written appeal to one (1) of the following:
Attn: Appeal
Board of Trustees
Missouri Consolidated Health Care Plan
PO Box 104355
Jefferson City, MO 65110
or by fax to (866) 346-8785
or online at www.mchcp.org
(5) In
reviewing appeals, notwithstanding any other rule, the board and/or staff may grant any appeals when there is
credible evidence to support approval under the following guidelines:
(A)
If a subscriber currently has coverage under the plan, MCHCP may approve the subscriber's request to enroll
his/her newborn retroactively to the date of birth if the appeal is received within three (3) months of the
child's birth date. Valid proof of eligibility must be included with the appeal;
(B) MCHCP may approve a subscriber's appeal and not hold the subscriber
responsible when there is credible evidence that there has been an error or miscommunication through the
subscriber's payroll/personnel office, MCHCP, or MCHCP vendor that was no fault of the subscriber;
(C) MCHCP may approve an appeal to change the type of medical or vision
plan that the subscriber elected or defaulted to during the annual open enrollment period if the request is
made within thirty-one (31) calendar days of the beginning of the new plan year, except that no changes will
be considered for Health Savings Account (HSA) Plan elections after the first MCHCP Health Savings Account
contribution has been transmitted for deposit to the subscriber's account. This guideline may not be used to
elect or cancel coverage or to enroll or cancel dependents. If a subscriber has his/her premium collected
pre-tax by qualified payroll deduction through a cafeteria plan, changes may be approved if the reason given
is allowed by the cafeteria plan;
(D) MCHCP may allow one (1)
reinstatement for termination due to non-payment per lifetime of account. Payment in full for all past and
current premiums due for reinstatement must be included with the appeal;
(E) MCHCP may approve a subscriber's appeal to terminate dental and/or
vision coverage if the appeal is received within thirty-one (31) calendar days of the beginning of the new
plan year and if no claims have been made or paid during the new plan year. If a subscriber has his/her
premium collected pre-tax by qualified payroll deduction through a cafeteria plan, termination may be
approved if the reason given is allowed by a cafeteria plan;
(F)
MCHCP may approve an appeal regarding late receipt of proof-of-eligibility documentation if the subscriber
can provide substantiating evidence that it took an unreasonable amount of time for the government agency
creating the documentation to provide subscriber with requested documentation;
(G) MCHCP may approve a subscriber's appeal to enroll after a deadline due
to late notice of loss of coverage from subscriber's previous carrier if the appeal is within sixty (60) days
from date of late notice;
(H) MCHCP may approve appeals, other
than those relating to non-payment, if subscriber is able to provide substantiating evidence that requisite
information was sent during eligibility period;
(I) MCHCP may
approve an appeal regarding plan changes retrospectively for subscribers who are new employees within thirty
(30) days of election of coverage if no claims have been filed with the previous carrier. If a subscriber has
his/her premium collected pre-tax by qualified payroll deduction through a cafeteria plan, changes may be
approved if the reason given is allowed by the cafeteria plan; and
(J) Once per lifetime of the account, MCHCP may approve an appeal where a
subscriber missed a deadline. MCHCP may only approve an appeal under this guideline if the appeal is received
within sixty (60) days of the missed deadline. This guideline may not be used to approve an appeal of a
voluntary cancellation or an appeal of a deadline that is statutorily
mandated.