8.3.1 Authority to File
(A) An Enrollee or the Enrollee’s legally authorized representative may file an Appeal; or (B) A provider may file an Appeal.
8.3.2 Timing
(A) The Enrollee or provider may file an Appeal of an Action within 30 calendar days from the date on the Contractor’s Written Notice of Action; or
(B) If the Action being appealed is to terminate, suspend or reduce a previously authorized course of treatment, the services were ordered by an authorized provider and the original period covered by the original authorization has not expired, and the Enrollee wants disputed services to continue during the Appeal process, then the Enrollee or provider shall file the Appeal on or before the later of the following:
(1) within 10 days of the Contractor mailing the Notice of Action; or (2) the intended effective date of the Contractor’s proposed Action.
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(A) The Enrollee or the provider may file an Appeal either orally or in writing.
(B) Unless the Enrollee or a provider requests an expedited resolution of the Appeal (which does not require a written follow-up request), the oral Appeal shall be followed with a written, signed Appeal. The written, signed Appeal must be received within five working days from the date of the oral Appeal.
(C) A provider may file the written, signed Appeal on behalf of the Enrollee and shall include the Enrollee’s signed written consent.
(D) If an Enrollee or provider requests an Appeal orally, the Contractor shall inform the Enrollee or provider that the oral filing of an Appeal must be followed with a written, signed appeal within five working days from the date of the oral Appeal.
(E) The Contractor shall give Enrollees any reasonable assistance in completing required forms for submitting a written Appeal or taking other procedural steps. Reasonable assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capacity.
(F) The Contractor shall acknowledge receipt of the Appeal either orally or in writing and explain to the Enrollee the process that must be followed to resolve the Appeal.
(G) The Contractor shall provide the Enrollee reasonable opportunity to present evidence, allegations of facts or law, in person as well as in writing. The Contractor shall inform the Enrollee of the limited time available for this in the case of an expedited Appeal resolution.
(H) The Contractors shall provide the Enrollee and the Enrollee’s authorized representative the opportunity, before and during the appeals process, to examine the Enrollee’s case file, including medical records, and any other documents and records considered during the appeals process.
(I) The Contractor shall include as parties to the appeal the Enrollee and the Enrollee’s representative or the legal representative of a deceased Enrollee’s estate.
(J) The Contractor shall ensure that the individuals who make the decision on an Appeal are individuals who:
(1) were not involved in any previous level of review or decision-making; and (2) if deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the Department, in treating the Enrollee’s condition or disease:
(i) an Appeal of a denial that is based on lack of medical necessity or
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(ii) an Appeal that involves clinical issues.
8.3.4 Time Frames for Appeal Resolution and Notification
(A) The Contractor shall resolve each Appeal and provide notice of resolution to affected parties as expeditiously as the Enrollee’s health condition requires but no later than 30 calendar days from the day the Contractor receives the written, signed Appeal.
(B) The Contractor may extend the time frame for resolving the Appeal and providing notice by up to 14 calendar days if:
(1) the Enrollee requests the extension; or
(2) the Contractor shows that (to the satisfaction of the Department, upon its request) there is no need for additional information and how the delay is in the Enrollee’s interest.
(C) If the Contractor extends the time frame, and the extension was not requested by the Enrollee, the Contractor shall give the Enrollee written notice of the reason for the delay.
8.3.5 Format and Content of Notice of Appeal Resolution
(A) The Contractor shall provide written Notice of Appeal Resolution to the affected parties.
The written Notice of Appeal Resolution shall include the following:
(1) the results of the Appeal resolution process and the date it was completed; and (2) for Appeals not resolved wholly in favor of the Enrollee, the Contractor shall include the following in the written Notice of Appeal Resolution:
(i) the right to request a State Fair Hearing and how to do so;
(ii) the right to request continuation of disputed services if the Appeal decision is to terminate, suspend or reduce a previously authorized course of treatment that was ordered by an authorized provider and the original period covered by the original authorization has not expired;
(3) how to request continuation of disputed services;
(4) a statement that the Enrollee may be liable for the cost of disputed services provided if the State Fair Hearing decision upholds the Contractor’s Action;
(5) the time frame for requesting a State fair hearing when continuation of disputed services is not requested and when continuation of disputed services is requested; and (6) as applicable, a copy of either:
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(i) the standard request form for a Medicaid State Fair Hearing; or
(ii) the request form for an expedited State Fair Hearing that the Enrollee must complete and submit to the Department to request a State Fair Hearing and continuation of disputed services;
(iii) the standard request form for an expedited State Fair Hearing if the Enrollee has an expedited Appeal.