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



6.02 Notices of Action and Continuation of Benefits



























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;


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






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.



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,



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





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.