6. GRIEVANCE SYSTEM AND PROVIDER APPEALS

The MCO shall establish and maintain a grievance system that meets all statutory and regulatory requirements. The MCO's grievance system shall include a grievance process, an appeal process and access to and participation in the DEPARTMENT'S administrative hearings process.

6.01 Grievances

a. The MCO shall have a system in place to handle grievances. Grievances are expressions of dissatisfaction about any matter, other than those matters that qualify as an action. The subject matters of grievances may include, but are not limited to, quality of care, rudeness by a provider or MCO staff person or failure to respect a Member's rights.

b. The MCO shall maintain adequate records to document the filing of a grievance, the actions taken, the MCO personnel involved and the resolution. The Department will prescribe a reporting format for tracking of grievances.

c. A Member, or a provider acting on a Member's behalf, may file a grievance either orally or in writing. The MCO shall acknowledge the receipt of each grievance and provide reasonable assistance with the process, including but not limited to providing interpreter services and toll free numbers with TTY/TTD and interpreter capability.

d. If the grievance involves a denial of expedited review of an appeal or some other clinical issue, the grievance must be reviewed by a health care professional with appropriate clinical expertise.

e. The MCO shall dispose of each grievance as expeditiously as the member's health requires. If the Member filed the grievance orally, the MCO may resolve the grievance orally, but shall maintain documentation of the grievance and its resolution. If the Member filed a written grievance, the resolution shall be in writing. If applicable, each grievance shall be handled by an individual who was not involved in any previous level of decision-making. Each grievance shall be disposed of in ninety (90) days or less.

6.02 Notices of Action and Continuation of Benefits

a. The MCO or its subcontractor (as duly authorized by the MCO) shall mail a notice of action to a Member when the MCO takes action upon a request for services from the Member's treating PCP, or other treating provider, functioning within his or her scope of practice as defined under state law. For purposes of this requirement, an "action" includes:

1.                  The denial or limited authorization of a requested service, including the type or 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 to act within the timeframes for utilization review decisions, as described in Section 3.39; and

5.                  The failure to provide access to services in a timely manner as required by 3.14(c)(1) through (c)(4) and 3.21(a)(4) or the failure to provide access to consultations and specialist referrals within three (3) months.

The notice of action requirements shall apply to all categories of covered services including transportation to medically necessary appointments.

The MCO is required to issue a notice for actions described in (a)(3) above if the denial of payment for services already rendered may or will result in the Member being held financially responsible. Such circumstances include, but are not limited to, the provision of emergency services that do not appear to meet the prudent layperson standard, the provision of services outside of the United States without prior authorization, and the provision of non-covered services with the Member's written consent as described in 3.47. The MCO is not required to issue a notice of action for the denial of payment for covered services that have already been provided to the Member if the denial is based on a procedural or technical issue, including but not limited to a provider's failure to comply with prior authorization rules for services that the Member has already received, incorrect coding or late filing by a provider for services that the Member has already received. In these circumstances, coverage of the service is not at issue and the Member may not be held financially liable for the services. Nothing herein shall relieve the MCO from its responsibility to issue a notice of action in all circumstances in which a provider requests prior authorization for a service and the request is denied in whole or in part, as required in (a)(1) above. Nothing herein shall relieve the MCO from its responsibility to hold a Member harmless for the cost of Medicaid covered services and its responsibility to ensure that the MCO's network providers hold a Member harmless for the cost of Medicaid covered services.

 

The MCO is required to issue a notice of action for actions described in (a)(5) above, only if the Member notifies the MCO of his or her inability to obtain timely access to services. In such instances, the MCO shall provide the Member with immediate assistance in accessing the services. If the Member has been unable to access emergency services, the MCO shall issue a notice of action immediately. For non-emergent services, if a Member contacts the MCO concerning the inability to access a covered service within the timeframes referenced in (a)(5) above, and three (3) business days later the Member has not accessed or made arrangements for receiving the service that are satisfactory to the Member, the MCO shall issue a notice of action.

b. The MCO shall issue a notice of action if the MCO approves a good or service that is not the same type, amount, duration, frequency or intensity as that requested by the provider, consistent with current DSS policy.

c. The MCO shall identify if the Member reads only a language other than English. For Members who do not read English, the notice of action shall be provided in accordance with Sections 3.28(a) and 3.29(h).

d. Except as provided in (h) below, the MCO shall mail an advance notice of action for a termination, suspension or reduction of a previously authorized service to a Member at least ten (10) days before the date of any action described in (a) above, consistent with current DSS policy. The MCO may shorten the period of advance notice to five (5) days before the date of action if: 1) the MCO has facts indicating that the action should be taken because of probable fraud by the Member; and 2) the facts have been verified, if possible, through secondary sources.

e. All notices related to actions described in (a) above shall clearly state or explain:

1.                  the action the MCO intends to take or has taken;

 

2.                  the reasons for the action;

3.                  the statute, regulation, the DEPARTMENT's Medical Services Policy section, or when there is no appropriate regulation, policy or statute, the HUSKY A contract provision that supports the action;

4.                  the address and toll-free number of the MCO's Member Services Department;

 

5.                  the Member's right to challenge the action by filing an appeal and requesting an administrative hearing;

6.                  the procedure for filing an appeal and for requesting an administrative hearing;

7.                  how the Member may obtain an appeal form and, if desired, assistance in completing and submitting the appeal form;

8.                  that the Member will lose his or her right to an appeal and administrative hearing if he or she does not complete and file a written appeal form with the DEPARTMENT within sixty (60) days from the date the MCO mailed the initial notice of action;

9.                  that the MCO must issue a decision regarding an appeal by the date that the administrative hearing is scheduled, but no more than thirty (30) days following the date the DEPARTMENT receives it;

10.              that, if the Member files an appeal he or she is entitled to meet with or speak by telephone with the MCO representative who will decide the appeal, and is entitled to submit additional documentation or written material for the MCO's consideration;

11.              that the Member may proceed automatically to an administrative hearing if he or she is dissatisfied with the MCO's appeal decision concerning the denial of coverage of goods or services or a reduction, suspension, or termination of ongoing goods or services, or if the MCO fails to render an appeal decision by the date the administrative hearing is scheduled;

12.              that at an administrative hearing, the Member may represent himself or herself or use legal counsel, a relative, a friend, or other spokesperson;

13.              that if the Member obtains legal counsel who will represent the Member during the appeal or administrative hearing process, the Member must direct his or her legal counsel to send written notification of the representation to the MCO and the DEPARTMENT;

14.              that if the circumstances require advance notice, the Member's right to continuation of previously authorized goods and services, provided that the Member files a appeal/request for administrative hearing form with the DEPARTMENT on or before the intended effective date of the MCO's action or within ten (10) calendar days of the date the notice of action is mailed to the Member, whichever is later;

15.              the circumstances under which expedited resolution is available and how to request expedited resolution; and

16. any other information specified by the DEPARTMENT.

f. In the case of a child who is under the care of the Department of Children and Families (DCF), the MCO must send the notice of action to the child's foster parents and the DCF contact person specified by the DEPARTMENT.

g. The NOA shall be mailed within the following timeframes:

 

1)                 for termination, suspension, or reduction of previously authorized Medicaid covered services, 10 days in advance of the effective date;

2)                 for standard authorization decisions to deny or limit services, as expeditiously as the Member's health condition requires, not to exceed fourteen (14) calendar days following receipt of the request for services;

3)                 if the MCO extends the fourteen day time frame for denial or limitation of a service as permitted in Section 3.39d (1)(i) and (ii), as expeditiously as the Member's condition requires and no later than the date the extension expires;

4)                 for service authorization decisions not reached within the timeframes in 3.39 (which constitutes a denial and thus is an adverse action), on the date the timeframe expires;

5)                 for expedited service authorization decisions as expeditiously as the Member's health condition requires and no later than three (3) business days after receipt of the request for services;

6)                 for denial of payment where the Member may be held liable, at the time of any action affecting the claim

7)                 for failure to provide timely access to services as expeditiously as the Member's health requires, but no later than three (3) business days after the Member contacts the MCO.

h. The ten (10) day advance notice requirements do not apply to the circumstances described in 42 CFR 431.213. Notice of action need not be sent to the Member ten (10) days in advance of the action, but may be sent no later than the date of action and will be considered an exception to the advance notice requirement, if the action is based on any of the following circumstances:

1) a denial of services;

2) the MCO has received a clear, written statement signed by the Member that:

a. the Member no longer wishes to receive the goods or services; or

b. the Member gives information which requires the reduction, suspension, or termination of the goods or services, and the Member indicates that he or she understands that this must be the result of supplying that information; and

3) the Member has been admitted to an institution where he or she is ineligible for the goods or services. In this instance, the Member must be notified on the notice of admission that any goods or services being reduced, suspended, or terminated will be reevaluated for medical necessity upon discharge, and the Member will have the right to appeal any post-discharge decisions.

 

If the circumstances are an exception to the advance notice requirement as set forth above the Member does not have the automatic right to continuation of ongoing goods or services. In these circumstances, however, and in any instance in which the MCO fails to issue an advance notice when required, the reduced, suspended, or terminated goods and services must be reinstated if the Member files a written appeal form with the DEPARTMENT within ten (10) days of the date the notice is mailed to the Member.

i. The MCO shall follow the requirements for continuation of services set forth in 42 CFR 438.420. The right to continuation of ongoing goods or services applies to the scope of services previously authorized. The right to continuation of services does not apply to subsequent requests for approval that result in denial of the additional request or re-authorization of the request at a different level than requested. For example, the right to continuation of services does not apply:

1.                  when a prescription (including refills) runs out and the

Member requests a new prescription for the same medication; or

2. to a request for additional home health care services following the expiration of the approved number of home health visits

The MCO shall treat such requests as a new service authorization request and provide a denial notice.

 

 

j. Notice of action is not required if the member's treating physician or PCP, using his or her professional judgment, refuses to prescribe (or prescribes an alternative to) a particular service sought by a member. Notice of action is also not required if the Member's treating physician or PCP, using his or her professional judgment, orders the reduction, suspension, or termination of goods or services. Such decisions do not constitute an action by the MCO. If, however, the Member disagrees with the provider and contacts the MCO to request authorization for the service the MCO shall conduct an expedited review of the request, according to the timeframe in 3.39(e). If the MCO affirms the provider's action to deny, terminate, reduce or suspend the service, the MCO shall issue a notice of action. If the Member requests an appeal and hearing, the MCO shall continue authorization for the services, to the extent services were previously authorized, unless the MCO determines that continued provision of the services could be harmful to the Member. The MCO shall also advise the Member of his or her right to a second opinion from another provider. Because only a licensed health care provider, and not the MCO, may prescribe or provide medical services, the Member may not be able to receive some or all of the requested goods or services while the appeal is pending. If the MCO approves the Member's request for the good or service, the MCO shall inform the Member of the approval and shall inform the Member of the right to a second opinion.

k. The DEPARTMENT will provide standardized notice of action forms to be used by the MCO and its subcontractors. The DEPARTMENT will also provide standardized appeal/hearing request forms to be used by the MCO and its subcontractors. The MCO and its subcontractors shall not alter the standard format of either form without prior, written approval of the DEPARTMENT.

l. The DEPARTMENT will conduct random reviews of the MCO and its subcontractors, as appropriate, to ensure that Members are sent accurate, complete and timely notices of action.

 

Sanction: If the DEPARTMENT determines during any audit or random monitoring visit to the MCO or one of its subcontractors that a notice of action fails to meet any of the criteria set forth herein, the DEPARTMENT may impose a strike towards a Class A sanction. If the deficiencies which give rise to a Class A sanction continue for a period in excess of ninety (90) days, the DEPARTMENT may impose a Class B sanction.

6.03 Appeals and Administrative Hearing Processes

a. The MCOs shall have a timely and organized appeals process. The appeals process shall be available for resolution of disputes between the MCO and its Members concerning the MCO's actions as defined in 6.02.

b. The MCO shall develop written policies and procedures for its appeals process. Those policies and procedures must be approved by the DEPARTMENT in writing and must include the elements specified in this contract. The MCO shall not be excused from providing the elements specified in this contract pending the DEPARTMENT's written approval of the MCO's policies and procedures.

c. The MCO shall maintain a record keeping system for appeals which shall include a copy of the appeal, the response, the resolution and supporting documentation.

d. The MCO must clearly specify in its Member handbook/packet the procedural steps and timeframes for filing an appeal and administrative hearing request, including the timeframe for maintaining benefits pending the conclusion of the appeal and administrative hearing processes. The Member handbook/packet shall also list the addresses, office hours, and toll-free telephone numbers for the Member Services office.

e. The MCO shall ensure that network providers and subcontractors are familiar with the appeal process and shall provide information on the process to providers and subcontractors. The MCO shall provide information on the appeal process to its providers and subcontractors at the time it enters into contracts or subcontracts. The MCO must ensure that appeal forms are available at each primary care site. At a minimum, appeals assistance must include providing forms on request, assisting the Member in filling out the forms upon request, and sending the completed form to the DEPARTMENT upon request.

f. The MCO shall develop and make available to Members and potential Members appropriate foreign language versions of appeals materials, including but not limited to, the standard information contained in notices of action and appeals forms. Such materials shall be made available in Spanish, English, or any other languages if more than five (5) percent of the MCO's Members in any county of the State served by the MCO speak the alternative language. Such foreign language materials must be approved, in writing, by the DEPARTMENT.

g. A Member may request an appeal either orally or in writing. When requesting an appeal orally, unless the member is seeking an expedited appeal review, the Member must follow up an oral request with a written, signed appeal form.. The MCO shall advise any member who requests an appeal orally, that the Member must file a written appeal form within sixty (60) days of the notice of action in order to receive an administrative hearing and the member must file an appeal form within ten (10) days of the mailing of the notice of action or the effective date of the intended action in order to continue previously authorized services pending the appeal and hearing. In all other respects, the process for pursuing an appeal and for requesting an administrative hearing shall be unified. The MCO and the DEPARTMENT shall treat the filing of a written appeal as a simultaneous request for an administrative hearing. The MCO shall attempt to resolve appeals at the earliest point possible. If the MCO is not able to render a decision by the time the administrative hearing is scheduled, the Member will automatically proceed to the administrative hearing.

h. Appeals may be filed by the Member, the Member's authorized representative, or the Member's conservator on a form approved by the DEPARTMENT. A provider, acting on behalf of the member and with the Member's written consent, may file an appeal. A provider may not file an administrative hearing request on behalf of a Member unless the authorized representative requirements in DSS Uniform Policy Manual Section 1525.05 are met. The MCO shall request a copy of the written consent from the Member. Appeals shall be mailed or faxed to a single address within the DEPARTMENT. The appeal form must state both the mailing address and fax number at the DEPARTMENT where the form must be sent. If the MCO or its subcontractor receive an appeal directly from a Member or the Member's authorized representative or conservator, the MCO shall date stamp and fax the appeal to the appropriate fax number at the DEPARTMENT within two (2) business days.

i. Upon receipt of a written appeal, the DEPARTMENT will schedule an administrative hearing and notify the Member and MCO of the hearing date and location. If a Member is disabled, the hearing may be scheduled for the Member's home, if requested by the Member.

j. The DEPARTMENT will date stamp and forward the appeal by fax to the MCO within two (2) business days of receipt. The fax to the MCO will include the date the Member mailed the appeal to the DEPARTMENT. The postmark on the envelope will be used to determine the date the appeal was mailed.

k. The MCO's review of the appeal must be carried out by an individual or individuals having final decisionmaking authority. Any appeal stemming from an action based on a determination of medical necessity or involving any other clinical issues must be decided by one or more physicians who were not involved in making that medical determination.

l. The MCO may decide an appeal on the basis of the written documentation available unless the Member requests an opportunity to meet with the individual or individuals making that determination on behalf of the MCO and/or requests the opportunity to submit additional documentation or other written material. The Member shall have a right to review his or her MCO record, including medical records and any other documents or records considered during the appeal process. The Member's right to access medical records shall be consistent with HIPAA privacy regulations and any applicable state or federal law.

m. If the Member wishes to meet with the decisionmaker, the meeting can be held via the telephone or at a location accessible to the Member, including the Member's home if requested by a disabled Member. Subject to approval of the DEPARTMENT's Regional Offices, any of the DEPARTMENT's office locations may be available for video conferencing. The MCO must invite a representative of the DEPARTMENT to attend any such meeting.

n. The MCO must mail to the Member a written appeal decision, described below, with a copy to the DEPARTMENT, by the date of the DEPARTMENT's administrative hearing as expeditiously as the Member's health condition requires, but no later than thirty (30) days from the date on which the appeal was received by the DEPARTMENT. If the Member is dissatisfied with the MCO's decision regarding the denial, reduction, suspension, or termination of goods or services, or if the MCO does not render a decision by the time of the administrative hearing, the Member may automatically proceed to the administrative hearing.

o. The MCO's written appeal decision must include the Member's name and address;

the provider's name and address; the MCO name and address; a complete description of the information or documents reviewed by the MCO; a complete statement of the MCO's findings and conclusions, including the section number and text of any contractual provision or DEPARTMENTAL policy provision that is relevant to the appeal decision; and a clear statement of the MCO disposition of the appeal.

p. Along with its written appeal decision, the MCO must remind the Member, on a form approved by the DEPARTMENT, that:

1. if the Member is dissatisfied with the MCO's appeal decision, the DEPARTMENT has already reserved a time to hold an administrative hearing concerning that decision;

2. that the Member has the right to automatically proceed to the administrative hearing, and that the MCO must continue previously authorized goods and services pending the administrative hearing decision;

3. if the appeal pertains to the suspension, reduction, or termination of goods or services which have been maintained during the appeals process, and the MCO's appeals decision affirms the suspension, reduction, or termination of goods or services, those goods or services will be suspended, reduced, or terminated in accordance with the MCO's appeals decision unless the Member proceeds to an administrative hearing; and

4. if the Member fails to appear at the administrative hearing, the Member's reserved hearing time will be cancelled and any disputed goods or services that were maintained will be suspended, reduced, or terminated in accordance with the MCO's appeals decision.

q.                  If the Member proceeds to an administrative hearing, the MCO must make its entire file concerning the Member and the appeal, including any materials considered in making its decision, available to the DEPARTMENT.

r.                    If the MCO fails to issue an appeal decision by the date that an administrative hearing is scheduled, but no later than thirty (30) days following the date the appeal was received by the DEPARTMENT, an administrative hearing will be held as originally scheduled. At the hearing, the MCO must prove good cause for having failed to issue a timely decision regarding the appeal. Good cause for the MCO's failure to issue a timely decision shall include, but not be limited to, documented efforts to obtain additional medical records necessary for the MCO's decision on the appeal and the Member's refusal to sign a release for medical records necessary for the decision on the appeal.

The MCO's inability to prove good cause shall constitute a sufficient basis for upholding the appeal, and the hearing officer, in his or her discretion, may uphold the appeal solely on that basis.

 

If the MCO proves good cause for having failed to issue a timely appeal decision, the hearing officer may order a continuance of the hearing pending the issuance of the appeal decision by a certain date, or the hearing officer may proceed with the hearing.

s.                   A representative of the MCO shall prepare the summary for the administrative hearing, subject to approval by the DEPARTMENT prior to the hearing, and shall present proof of all facts supporting its initial action if the administrative hearing proceeds in the absence of an appeal decision. The MCO shall submit a final, signed hearing summary to the DEPARTMENT no later than five (5) business days prior to the scheduled hearing date. The MCO's representative shall also present any provisions of this contract or any DEPARTMENT policies which support its decision.

t.                    If the Member is represented by legal counsel at the hearing and has not notified either the DEPARTMENT or the MCO of the representation, the MCO may request a continuance of the hearing or may ask the hearing officer to hold the hearing record open for additional evidence or submissions. The decision as to whether a continuance will be granted or the record will be held upon is within the hearing officer's discretion.

u. If a representative of the MCO fails to attend a scheduled session of an administrative hearing, the MCO's failure to attend shall constitute a sufficient basis for upholding the appeal, and the hearing officer, in his or her discretion, may close the hearing and uphold the appeal solely on that basis. This provision shall not apply unless the MCO receives notice of the hearing at least seven (7) business days prior to the administrative hearing.

v. If the DEPARTMENT is advised that the Member does not intend to proceed to an administrative hearing, the DEPARTMENT will fax such notice to the MCO.

w. The MCO must designate one primary and one back-up contact person for its

appeal/administrative hearing process.

x If the DEPARTMENT's hearing officer reverses the MCO's decision to deny,

limit or delay services that were not furnished while the appeal was pending, the MCO shall authorize or provide the disputed services promptly, and as expeditiously as the Member's health condition requires.

6.04 Expedited Review and Administrative Hearings

a. Subject to Section 6.02 above, the appeal process must allow for expedited review. If the appeal contains a request for expedited review, it will be forwarded by fax to the MCO within one business day of receipt by the DEPARTMENT. The fax will include the date the Member mailed the appeal. The postmark on the envelope will be used to determine the date the appeal was mailed. If the MCO receives an oral request for expedited appeal, the MCO shall notify the DSS liaison by fax or telephone within one business day of the oral request.

b. The MCO must determine, within one business day of receiving the appeal which contains a request for an expedited review from the DEPARTMENT, or within one business day of receiving an oral request for an expedited appeal, whether to expedite the appeal or whether to perform it according to the standard timeframes. If the Member's provider indicates or the MCO determines that the appeal meets the criteria for expedited review, the MCO shall notify the DEPARTMENT immediately that the MCO will be conducting the appeal on an expedited basis.

c.                   An expedited appeal must be performed when the standard timeframes for determining a appeal could seriously jeopardize the life or health of the Member or the Member's ability to attain, maintain or regain maximum function. The MCO must expedite its review in all cases in which the Member's provider indicates, in making the request for expedited review on behalf of the Member or supporting the member's request, that taking the time for a standard appeal review could seriously jeopardize the Member's life or health or ability to attain, maintain, or regain maximum function and if the DEPARTMENT requests the MCO to conduct an expedited review because the DEPARTMENT believes a specific case meets the criteria for expedited review.

d. If the MCO denies a request for expedited review, the MCO shall perform

the review within the standard timeframe and make reasonable efforts to give the Member prompt oral notice of the denial and follow up within two calendar days with a written notice.

e. An expedited review must be completed and an appeal decision must be issued within a timeframe appropriate to the condition or situation of the Member, but no more than three (3) business days from the DEPARTMENT's receipt of the written appeal or three (3) business days from an oral request received by the MCO.

f.                  The MCO may extend the timeframe for decisions in paragraph e by up to 14 days if : 1) the Member requests the extension or 2) MCO can demonstrate that the extension is in the member's interest because additional information is needed to decide the appeal and if the timeframe is not extended, the appeal will be denied. The DEPARTMENT may request this documentation from the MCO.

g.                   The MCO shall ensure that no punitive action is taken against a provider who requests an expedited appeal or supports a Member's appeal.

h.                    The MCO shall issue a written appeal decision for expedited appeals. The written notice of the resolution must meet the requirements of 6.03(o) and (p). The MCO shall also make reasonable efforts to provide the Member oral notice of an expedited appeal decision.

i. The DEPARTMENT also provides expedited administrative hearings for HUSKY A Members, where required. The DEPARTMENT shall issue a hearing decision as expeditiously as the Member's health condition requires, but no later than three (3) working days after the DEPARTMENT receives from the MCO, the case file and information for any appeal that meets the requirements for an expedited hearing. A Member is entitled to an expedited hearing for the denial of a service if the denial met the criteria for expedited appeal but was not resolved within the expedited appeals timeframe or was resolved within the expedited appeals timeframe, but the appeals decision was wholly or partially adverse to the Member.

Sanction: If the MCO fails to provide expedited appeals in appropriate circumstances, the DEPARTMENT may impose a Class B sanction pursuant to Section 7.05.