Current through Bulletin 2024-06, March 15, 2024
(1) The procedures
in Section R410-14-20 apply only to appeals
or requests for agency action arising from actions taken by an MCO.
(2) For this section, the following
definitions apply:
(a) "Adverse benefit
determination" means one of the following actions by an MCO:
(i) the denial or limited authorization of a
requested service, including the type and level of services, requirements for
medical necessity, appropriateness, setting, or effectiveness of a covered
benefit;
(ii) the reduction,
suspension, or termination of a previously authorized service;
(iii) the denial, in whole or in part, of
payment for a service;
(iv) the
failure to provide services in a timely manner;
(v) the failure to act within the time frames
provided in 42 CFR
438.408(b);
(vi) the denial of a request by a Medicaid
enrollee who is a resident of a rural area with only one MCO to exercise the
enrollee's right under 42
CFR 438.52(b)(2)(ii) to
obtain services outside of the network;
(vii) the denial of an enrollee's request to
dispute a financial liability, including cost sharing, copayments, premiums,
deductibles, coinsurance, and other enrollee financial liabilities;
or
(viii) the restriction of a
Medicaid enrollee that utilize services at a frequency or amount that are not
medically necessary, in accordance with state utilization
guidelines.
(b) "Appeal"
means a review by an MCO of an action as defined in Section
R410-14-20 or a request for DIH
to review a final decision made by an MCO as a result of the MCO's appeal
process.
(c) "Grievance" means an
expression of dissatisfaction about any matter other than an adverse benefit
determination. Grievances may include the quality of care or services provided,
and aspects of interpersonal relationships such as rudeness of a provider or
employee, or failure to respect the enrollee's rights regardless of whether
remedial action is requested. Grievance includes an enrollee's right to dispute
an extension of time proposed by the MCO to make an authorization
decision.
(d) "Grievance and appeal
system" means the processes the MCO implements to handle appeals of an action
and grievances.
(e) "Party" means
the agency, or other person commencing an adjudicative proceeding, respondents,
and any MCO who is or may be obligated to pay a claim or provide a benefit or
service to a member.
(3)
An MCO shall establish a grievance and appeal system in accordance with this
rule, 42 CFR
431.200 et seq. and 438.400 et seq. and the
MCO's contractual obligations entered into with DIH.
(4) The MCO grievance and appeal system shall
include a written internal grievance and appeal procedure for aggrieved person
to challenge an action by the MCO.
(5) The MCO shall provide to its enrollees
and providers written information that explains the grievance and appeal
procedure including a right to request a state fair hearing in accordance with
this rule.
(6) The MCO's notice of
action shall comply with the requirements set forth in Section
R410-14-3,
42 CFR
438.402, and
42 CFR
438.404.
(7) The MCO's written notice of final
decision shall comply with the requirements set forth in
42 CFR
438.408 and include an explanation of the
aggrieved person's right to a state fair hearing pursuant to this
rule.
(8)
(a) Unless otherwise stated in this section,
an aggrieved party may appeal an MCO final written disposition on an action by
requesting a state fair hearing in accordance with this rule. The hearing
request must include a copy of the final written notice of the MCO
disposition.
(b) An aggrieved
person must exhaust the MCO grievance and appeal procedure before requesting a
state fair hearing for an action other than the restriction of a Medicaid
enrollee. In the case of an MCO that fails to adhere to the notice and timing
requirements in 42 CFR
438.400 et seq., the enrollee is considered
to have exhausted the MCO's appeals process. The hearing request must include a
copy of the final written notice of the MCO decision.
(c) The aggrieved party must request a
hearing within 120 days from the date of the MCO final written notice of the
decision.
(d)
(i) If an appeal is based on a dispute
regarding the payment liability between two or more MCOs, the aggrieved person
is not required to exhaust the MCO grievance procedure for each MCO before
requesting a state fair hearing under this rule.
(ii) If DIH identifies an MCO that may be
liable to pay the claim and did not participate in the underlying grievance
procedure, it shall send notice to that MCO that it may be subject to liability
and its right to participate in the state fair hearing.
(iii) If more than one MCO is party to the
state fair hearing, DIH shall provide a notice to all parties that shall
include the identity of all parties, the reason for the dispute, a copy of the
hearing request, and a statement that the MCO that did not participate in the
underlying grievance and appeal procedure may be subject to payment liability
and its right to participate in the state fair hearing.
(e) DIH may, but is not required to, file an
answer or other response or position statement in the hearing proceeding at any
time so long as it gives notice to other parties no less than five days before
the hearing. If DIH chooses not to file a response or position statement, it
does not waive its right to participate in the hearing.
(9)
(a) If
the MCO or state fair hearing officer reverses a decision to deny, limit, or
delay services that were not furnished while the appeal was pending, the MCO
must authorize or provide the disputed services promptly and as expeditiously
as the enrollee's health condition requires, but before 72 hours from the date
it receives notice reversing the determination.
(b) If the MCO or state fair hearing officer
reverses a decision to deny authorization of services and the enrollee received
the disputed services while the appeal was pending, the MCO or the state must
pay for those services in accordance with state policy and
rules.