Current through Register Vol. 35, No. 18, September 24, 2024
An appeal is a request for review by the CSC of a CSC
action.
A. An action is defined as:
(1) the denial or limited authorization of a
requested service, including the type of level of service;
(2) the reduction, suspension, or termination
of a previously authorized service;
(3) the denial, in whole or in part, of
payment for a service;
(4) the
failure of the CSC to provide services in a timely manner, as defined by HCA;
or
(5) the failure of the CSC to
complete the authorization request in a timely manner as defined in
42 CFR
438.408.
B. The CSC shall mail a notice of action to
the recipient and provider within 10 days of the date of the action, except for
denial of claims that may result in recipient financial liability, which
requires immediate notification. The notice shall contain, but not be limited,
to the following:
(1) the action CSC has
taken or intends to take;
(2) the
reasons for the action;
(3) the
recipient's or the provider's right to file an appeal of the CSC action through
the CSC;
(4) the recipient's right
to request an HCA fair hearing and what the process would be;
(5) the procedures for exercising the rights
specified;
(6) the circumstances
under which expedited resolution of an appeal is available and how to request
it; and
(7) the recipient's right
to have benefits continue pending resolution of an appeal, how to request the
continuation of benefits, and the circumstances under which the recipient may
be required to pay the costs of continuing these benefits.
C. A recipient may file an appeal of a CSC
action within 90-calendar days of receiving the CSC's notice of action. The
legal guardian of the recipient for a minor or an incapacitated adult, a
representative of the recipient as designated in writing to the CSC, or a
provider acting on behalf of the recipient with the recipient's written
consent, have the right to file an appeal of an action on behalf of the
recipient.
D. The CSC has
30-calendar days from the date the initial oral or written appeal is received
by the CSC to resolve the appeal.
E. The CSC shall have a process in place that
ensures that an oral or written inquiry from a recipient seeking to appeal an
action is treated as an appeal (to establish the earliest possible filing date
for the appeal). The CSC shall use its best efforts to assist recipients as
needed with the written appeal.
F.
Within five working days of receipt of the appeal, the CSC shall provide the
grievant with written notice that the appeal has been received and the expected
date of its resolution. The CSC shall confirm in writing receipt of oral
appeals, unless the recipient or the provider requests an expedited
resolution.
G. The CSC may extend
the 30 days time frame by 14 calendar days if the recipient requests the
extension, or the CSC demonstrates to HCA that there is need for additional
information, and the extension is in the recipient's interest. For any
extension not requested by the recipient, the CSC shall give the recipient
written notice of the extension and the reason for the extension within two
working days of the decision to extend the time frame.
H. The CSC shall provide the recipient or the
recipient's representative a reasonable opportunity to present evidence of the
facts or law, in person as well as in writing.
I. The CSC shall provide the recipient or the
representative the opportunity, before and during the appeals process, to
examine recipient's case file, including medical or clinical records (subject
to HIPAA requirements), and any other documents and records considered during
the appeals process. The CSC shall include as parties to the appeal the
recipient and their representative, or the legal representative of a deceased
recipient's estate.
J. For all
appeals, the CSC shall provide written notice within the 30-calendar-day
timeframe for resolution to the grievant, legal guardian, representative, and
provider acting on behalf of the recipient.
(1) The written notice of the appeal
resolution shall include, but not be limited to, the following information:
(a) the results of the appeal resolution;
and
(b) the date it was
completed.
(2) The
written notice of the appeal resolution for appeals not resolved wholly in
favor of the recipient shall include, but not be limited to, the following
information:
(a) the right to request an HCA
fair hearing and how to do so:
(b)
the right to request receipt of benefits while the hearing is pending, and how
to make the request; and
(c) that
the recipient may be held liable for the cost of continuing benefits if the
hearing decision upholds the CSC's action.
K. The CSC may continue benefits while the
appeal or the HCA fair hearing process is pending.
(1) The CSC shall continue the recipient's
benefits if all of the following are met:
(a)
the recipient or the provider files a timely appeal of the CSC action within 10
days of the date on the notice of action from the CSC);
(b) the appeal involves the termination,
suspension, or reduction of a previously authorized course of
treatment:
(c) the services are
ordered by an authorized provider;
(d) the recipient requests extension of
benefits.
(2) The CSC
shall provide benefits until one of the following occurs:
(a) the recipient withdraws the
appeal;
(b) 10 days have passed
since the date of the resolution letter, provided the resolution of the appeal
was against the recipient and the recipient has taken no further
action;
(c) HCA issues a hearing
decision adverse to the recipient;
(d) the time period or service limits of a
previously authorized service has expired.
(3) If the final resolution of the appeal is
adverse to the recipient, that is, the CSC's action is upheld, the CSC may
recover the cost of the services furnished to the member while the appeal was
pending, to the extent that services were furnished solely because of the
requirements of this section and in accordance with the policy in
42 CFR
431.230(b).
(4) If the CSC or HCA reverses a decision to
deny, limit, or delay services, and these services were not furnished while the
appeal was pending the CSC shall authorize or provide the disputed services
promptly and as expeditiously as the recipient's health condition
requires.
(5) If the CSC or HCA
reverses a decision to deny, limit or delay services and the recipient received
the disputed services while the appeal was pending, the CSC shall pay for these
services.
