New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 506 - MEDICAID CARE MANAGEMENT (MCM)
Section He-W 506.08 - MCO Appeal Process

Universal Citation: NH Admin Rules He-W 506.08

Current through Register No. 40, October 3, 2024

(a) The MCO or DO appeal process shall address members' requests for the appeal of any adverse benefit determination or action taken by the MCO or DO.

(b) A member who wants to appeal an action taken by the MCO or DO shall utilize the MCO or DO appeal process.

(c) A member, the member's authorized representative, the member's legal guardian appointed in accordance with He-W 803.01, or the member's provider acting on behalf of the member and with the member's written consent may file an appeal with the MCO or DO. However, a provider acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.

(d) All requests for appeals shall be made within 60 calendar days of the date on the MCO's or DO's notice of action.

(e) All requests for appeals shall be made either orally or in writing. An oral request for an appeal shall be followed by a written request, unless the request is for expedited resolution as described in (g) below.

(f) The MCO or DO shall resolve standard appeals within 30 calendar days from the day the MCO or DO receives the appeal.

(g) A person in (c) above may request an expedited resolution of an appeal when taking the time needed for a standard resolution could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(h) The MCO or DO shall resolve an expedited appeal within 72 hours of receiving the appeal.

(i) The MCO or DO may extend the timeframes to resolve standard and expedited appeals up to 14 calendar days if:

(1) The member requests the extension; or

(2) The MCO or DO demonstrates that there is a need for additional information in order to resolve the appeal and the extension is in the member's interest.

(j) If the MCO or DO extends the timeframes not at the request of the member in accordance with (i)(2) above, then the MCO or DO shall:

(1) Make reasonable efforts to give the member prompt oral notice of the delay by providing a minimum of 3 oral attempts to contact the member at various times of the day, on different days within 2 calendar days of the MCO's or DO's decision to extend the timeframe;

(2) Within 2 calendar days of the MCO's or DO's decision to extend, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; and

(3) Resolve the appeal as expeditiously as the member's health condition requires and no later than the date the extension expires.

(k) A member's benefits shall be continued during an appeal if:

(1) The member requests a continuation of benefits on or before the later of the following:
a. Within 10 calendar days of the date the MCO or DO mails the notice of action; or

b. The intended effective date of the MCO's or DO's proposed action;

(2) The appeal involves the termination, suspension, or reduction of previously authorized services;

(3) The services were ordered by an authorized provider; and

(4) The period covered by the original authorization has not expired.

(l) If the MCO's or DO's action is upheld in a hearing, the MCO or DO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.

(m) The MCO or DO grievance process shall not preclude a member's ability to pursue client rights protection under He-M 204.

#10410, eff 9-13-13

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