Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

2.0 DSS for HUSKY A and DCF for Voluntary shall:

1. Provide the following standard forms and instructions, the format and content of which may not be altered without the written approval of DSS:

a. NOA-DPD-M used for HUSKY A denials and partial denials.

a. Yes

a. NA

a. NA

b. NOA-RST-M used for HUSKY A reduction, suspension or termination of ongoing services.

b. Yes

b. NA

b. NA

c. Denial - S used for HUSKY B denials.

c. NA

c. NA

c. Yes

d. Denial - V used for Voluntary Services denials.

d. NA

d. Yes

d. NA

e. Grievance /Administrative Hearing Request Form for HUSKY A.

e. Yes

e. NA

e. NA

f. Grievance /DOI Instructions for HUSKY B.

f. NA

f. NA

f. Yes

g. Grievance / DCF Instructions for Voluntary Services.

g. NA

g. NA

g. NA

2. Approve the Grievance process and changes to it.

2. Yes

2. Yes

2. Yes

3. Approve the Grievance decision form and changes to it.

3. Yes

3. Yes

3. Yes

4. Schedule an administrative hearing within thirty (30) calendar days of receipt of the grievance and notify the Recipient and Contractor of the hearing date and location. If a Recipient is disabled, the hearing may be scheduled for the Recipient's home, if requested by the Recipient.

4. Yes

4. NA

4. NA

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

5. Schedule an administrative hearing for Voluntary Services within thirty (30) calendar days of receipt of the hearing request and notify the Contractor of the hearing date and location.

5. NA

5. Yes

5. NA

6. Date stamp and forward the grievance by fax to the Contractor within two (2) business days of receipt. The fax to the Contractor will include the date the Recipient mailed the appeal to DSS. The postmark on the envelope will be used to determine the date the appeal was mailed.

6. Yes

6. NA

6. NA

7. Fax a request for expedited review to the Contractor within one business day of receipt by DSS when the recipient's grievance contains a request for expedited review. The fax will include the date the Recipient mailed the appeal.

7. Yes

7. NA

7. NA

8. Hear and determine all administrative hearings and expedited administrative hearings.

8. Yes

8. Yes

8. NA

9. Fax a notice to the Contractor not to proceed to an administrative hearing when the recipient advises DSS or DCF not to proceed to an administrative hearing.

9. Yes

9. Yes

9. NA

10. Provide expedited administrative hearings for HUSKY A Recipients if a Recipient's physician demonstrates that it would put the Recipient's life at risk or pose serious risk of illness or injury to follow the regular timeframes for administrative hearings. DSS will notify the Contractor of the granting of any Recipient's request for an expedited administrative hearing.

10. Yes

10. NA

10. NA

3.0 The Departments shall:

1. Review reports related to grievances and administrative hearings.

1. Yes

1. Yes

1. Yes

2. Determine performance non-compliance and sanction application.

2. Yes

2. Yes

2. Yes

4.0 The Contractor shall:

1. Complete the appropriate Notice of Action (NOA) for HUSKY A or Denial Form for HUSKY B or Voluntary including the specific reason for denial in English and in Spanish and mail no later than the date of action of the decision unless specified otherwise under the following conditions:

1. Yes

1. Yes

1. Yes

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

a. 1) When the Contractor denies, partially denies or approves a HUSKY A good or service that is not of the type, amount, duration or frequency or intensity as that requested by the recipient's treating provider, functioning within his or her scope of practice as defined under state law. These requests would also include additional requests and/or re-authorization requests.

a.1) Yes

a.1) NA

a.1) NA

a. 2) When the Contractor denies a good or service, which is a HUSKY B or Voluntary Services good or service, that is requested by the recipient's treating provider, functioning within his or her scope of practice as defined under state law.

a.2) NA

a.2) Yes

a.2) Yes

b. When the Contractor reduces, suspends, or terminates ongoing goods or services being provided to a recipient, the Contractor shall mail the NOA ten (10) days in advance of the reduction, suspension or termination.

b. Yes

b. NA

b. NA

c. If additional information is needed for the Contractor's consideration of a request for approval of coverage of goods or services and the provider does not respond to the request for additional information within ten (10) business days and the Contractor still does not have adequate information to approve the request. The NOA shall state that the reason for the action is the lack of sufficient information from the provider.

c. Yes

c. NA

c. NA

d. The Recipient has been admitted to an institution where he or she is ineligible for the goods or services that he or she was receiving prior to admission. In this instance, the Recipient shall be notified on the NOA that any goods or services being reduced, suspended, or terminated will be reevaluated for medical necessity upon discharge, and the Recipient will have the right to appeal any post-discharge decisions.

d. Yes

d. NA

d. NA

2. Mail the applicable NOA or Denial to one of the following individuals:

a. Recipient, if the recipient is 18 years of age or older

a. Yes

a. Yes

a. Yes

b. Recipient's head of household if the recipient is under the age of 18

b. Yes

b. Yes

b. Yes

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

c. For a child who is under the custody of the Department of Children and Families the Contractor shall send the NOA to the identified person at DCF's central office

c. Yes

c. Yes

c. Yes

3. 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 or partial denial. The Contractor shall treat such requests as a new service authorization request and provide a NOA.

3. Yes

3. NA

3. NA

4. If the Contractor reduces, suspends, or terminates an existing authorization for ongoing services being provided to a recipient as described above in 1.b, circumstances which are subject to the 10 day advance notice requirement, the Recipient has a right to continuation of ongoing goods and services, provided that:

4. Yes

4. NA

4. NA

a. the Recipient files a grievance/request for administrative hearing form with the DSS within ten (10) calendar days of the date the NOA is mailed to the Recipient; and

a. Yes

a. NA

a. NA

b. the reduction, suspension, or termination of goods or services was not ordered by the Recipient's treating physician or PCP, functioning within his or her scope of practice as defined under state law.

b. Yes

b. NA

b. NA

For Policies and Procedures, the contractor shall:

5. a) Develop and implement a timely and organized grievance process to resolve disputes between the Contractor and Recipients concerning the Contractor's denial, partial denial, reduction, suspension or termination of goods or services or the Contractor's failure to respond to a request for goods and services.

5.a. Yes

5.a. NA

5.a. NA

5. b) Develop and implement a timely and organized grievance process to resolve disputes between the Contractor and Recipients concerning the Contractor's denial of goods or services or the Contractor's failure to respond to a request for goods and services.

5.b. NA

5.b. Yes

5.b. Yes

6. Develop written policies and procedures for its grievance process.

6. Yes

6. Yes

6. Yes

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

7. Maintain a record keeping system for grievances, which shall include a copy of the grievance, the response, the resolution and supporting documentation.

7. Yes

7. Yes

8. Specify in its Recipient handbook/packet the procedural steps and timeframes for filing a grievance and hearing request including for each program the timeframe for maintaining benefits pending the conclusion of the grievance and administrative hearing process. The Recipient handbook/packet shall also list the address, office hours, and toll-free telephone numbers for the Recipient Services office.

7. Yes

7. Yes

Steps for Filing a Grievance:

The Recipient shall file a Grievance within sixty (60) days of the receipt of the NOA/Denial by the Recipient, any member of the Recipient's assistance unit ("unit"), the unit's authorized representative, or a conservator on a form provided by the Departments.

Yes

Yes

Yes

a. Recipient shall file a written signed grievance in order to receive an administrative hearing before DSS, concerning the Contractor's denial, partial denial, reduction, suspension, or termination of goods or services. The process for pursuing a grievance and for requesting an administrative hearing shall be unified. The Contractor and DSS shall treat the filing of a grievance as a simultaneous request for an administrative hearing.

a. Yes

a. NA

a. NA

b. 1) Grievances shall be mailed or faxed to a single address within DSS for HUSKY A.

b.1) Yes

b.1) No

b.1) No

b. 2) Grievances shall be mailed or faxed to a single address at the Contractor.

b.2) NA

b.2) Yes

b.2) Yes

c. 1) If the Contractor receives a grievance form, the Contractor shall date stamp and fax the grievance to the appropriate fax number at DSS within two (2) business days.

c.1) Yes

c.1) NA

c.1) NA

c. 2) The contractor shall date stamp the grievance, which be used to determine whether an appeal was timely filed.

c.2) NA

c.2) Yes

c.2) Yes

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

For Review of the Grievance by the Contractor, the Contractor shall:

a. Designate one primary and one back up contact person for its grievance/ Administrative hearing process.

a. Yes

a. Yes

a. Yes

b. Review the grievance by an individual or individuals having final decision making authority. Any grievance stemming from an action based on a determination of medical necessity shall be decided by one or more physicians who were not involved in making that medical decision related to the denial. The physicians shall be doctoral level behavioral health specialists with at least one of the physicians having child or adult expertise depending on the age of the recipient, with expertise in the area that is the focus of the grievance.

b. Yes

b. Yes

b. Yes

c. (May) decide a grievance on the basis of the written documentation available unless the Recipient requests an opportunity to meet with the individual or individuals making that determination on behalf of the Contractor and/or requests the opportunity to submit additional documentation or other written material.

c. Yes

c. Yes

c. Yes

d. If the Recipient wishes to meet with the decision-maker, the meeting can be held via the telephone or at a location accessible to the Recipient, including the Recipient's home if requested by a disabled Recipient. Subject to approval of DSS' Regional Offices, any of the DSS office locations may be available for video conferencing.

d. Yes

d. Yes except home visits are not required.

d. Yes except home visits are not required.

e. Attempt to resolve grievances at the earliest point possible but no later than the date of the Administrative hearing.

e. Yes

e. NA

e. NA

f. 1) Mail to the Recipient, by certified mail, a written grievance determination, described below, with a copy to DSS, by the date of the DSS administrative hearing.

f.1) Yes

f.1) NA

f.1) NA

f. 2) Mail to the Recipient, by certified mail, a written grievance determination, described below, with a copy to DSS, within thirty (30) days of receipt of the grievance.

f.2) NA

f.2) Yes

f.2) Yes

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

1. The Contractor's written grievance determination shall include the Recipient's name and address; the provider's name and address; the Contractor name and address; a complete description of the information or documents reviewed by the Contractor; a complete statement of the Contractor's findings and conclusions, including the legal authority that is the basis of the grievance determination; and a clear statement of the Contractor disposition of the grievance.

1. Yes

1. Yes

1. Yes

2. The grievance determination shall be responded to in the language that the grievance was submitted.

2. Yes

2. Yes

2. Yes

3. Along with the Grievance determination, The Contractor shall remind the recipient on a form, which shall be approved by the Departments, that:

(a) if the Recipient is dissatisfied with the Contractor's denial, partial denial, reduction, suspension, or termination of goods or services, DSS has already reserved a time to hold an administrative hearing concerning that determination;

(b) if the Recipient fails to appear at the administrative hearing, the Recipient'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 Contractor's grievance determination.

(c) Only If the Recipient is entitled to continuation of services, the Contractor shall indicate that the services will be continued for the duration of the existing authorization until the result of the Administrative hearing.

3. Yes

3. NA

3. NA

Administrative Hearing:

a. 1) If the HUSKY A recipient is dissatisfied with the results of the grievance determination or the Contractor has not issued the determination, the DSS Administrative hearing will occur as scheduled.

a.1) Yes

a.1) No

The Admin. Hearing Process does not apply to HUSKY B. See the external Appeal to the DOI section below.

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

a. 2.) If the recipient is dissatisfied with the results of the grievance determination, the recipient has thirty (30) days from receipt of the grievance to request a DCF Administrative hearing.

a.2) NA

a.2) Yes

b. If the Recipient proceeds to an administrative hearing, the Contractor shall make its entire file concerning the Recipient and the grievance, including any materials considered in making its determination, available to DSS or DCF, as appropriate. This file shall also include a summary of the clinical justification supporting the decision and subsequent grievance determination.

b. Yes

b. Yes

c. The failure of a Contractor's representative to attend a scheduled session of an administrative hearing shall result in a sanction.

c. Yes

c. Yes

d. The Contractor shall comply with the determination of the Administrative Hearing.

d. Yes

d. Yes

Expedited Review:

a. The grievance process shall allow for expedited review. The postmark on the envelope will be used to determine the date the appeal was mailed.

a. Yes

a. Yes

a. Yes

b. The Contractor shall determine, within one business day of receiving the grievance that contains a request for an expedited review, whether to expedite the review or whether to perform a review according to the standard timeframes.

b. Yes

b. Yes

b. Yes

c. An expedited review shall be performed when the standard timeframes for determining a grievance could jeopardize the life or health of the Recipient or the Recipient's ability to regain maximum function. The Contractor shall expedite its review in all cases in which such a review is requested by the Recipient's treating physician or PCP, functioning within his or her scope of practice as defined under state law, or by DSS or the Departments.

c. Yes

c. Yes

c. Yes

d. Unless the Recipient asks to meet with the decision maker or to submit additional information, an expedited review shall be completed and a grievance decision shall be issued within a timeframe appropriate to the condition or situation of the Recipient, but no more than three (3) business days from the Contractor's receipt of the grievance from DSS.

d. Yes

d. Yes except received directly form the Recipient.

d. Yes except received directly form the Recipient.

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

e. If the Recipient asks to meet with the decision maker and/or submit additional information, the decision maker shall offer to meet with the Recipient within three (3) business days of receiving the grievance from DSS, and the Contractor shall issue its determination not later than five (5) business days after receiving the grievance. The meeting with the Recipient can be held via the telephone or at a location accessible to the Recipient, and subject to approval of DSS' Regional Offices, any of DSS' office locations may be available for video conferencing

e. Yes

e. Yes except received directly from the Recipient.

e. Yes except received directly from the Recipient.

External Appeal to the Department of Insurance (HUSKY B Only)

1. If the Recipient has exhausted the Contractor's internal appeals process and has received a final written determination from the Contractor upholding the Contractor's original denial of the good or service, the Recipient may file an external appeal with the Department of Insurance ("DOI") within thirty (30) days of receiving the final written appeal determination;

NA, see Admin. Hearing Above.

NA, see Admin. Hearing Above.

1. Yes

2. The Recipient may be required to file a filing fee for the DOI appeal. DSS shall pay the filing fee on behalf of any Recipient whose family economic filing unit income exceeds 185 percent of the federal poverty level but does not exceed 300 percent of the federal poverty level (Recipients in Income Bands 1 and 2).

2. Yes

3. The non-refundable filing fee for an external appeal through DOI is $25;

3. Yes

4. The Recipient will be asked to submit certain information in support of his or her appeal request, including a photocopy of his or her HUSKY B enrollment card. The Recipient (or the Recipient's legal representative) will also be asked to sign a release of medical records;

4. Yes

5. The DOI will assign the appeal to an outside, independent entity. The reviewers will conduct a preliminary review and determine whether the appeal meets eligibility for review. The Recipient will be notified within five (5) business days of DOI's receipt of the request whether the appeal has been accepted or denied for full review;

5. Yes

6. The Contractor shall advise Recipients that they may obtain information about the external review process and request a form from the DOI, P.O. Box 816, Hartford, CT 06142 or at (860) 297-3862; and

6. Yes

Process Requirement

HUSKY A

Voluntary Services

HUSKY B (SCHIP)

7. A copy of the DOI External Appeal Consumer Guide.

7. Yes

8. The Contractor shall comply with DOI's external appeal determination.

8. Yes