8.4.1 General Requirements
(A) The Contractor shall establish and maintain an expedited review process when:
(1) The Contractor determines, based either upon a request from an Enrollee or in the Contractor’s own judgment, that the standard timeframe for Appeal could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain or regain maximum function; or
(2) A provider indicates that the standard timeframe for Appeal could seriously
jeopardize the Enrollee’s life or health or ability to attain, maintain or regain maximum function.
8.4.2 Authority to File
The Enrollee or a provider may file an expedited Appeal request either orally or in writing. Oral requests for expedited Appeal do not require a follow-up written request.
8.4.3 Timing
(A) The Enrollee or provider may file an Appeal of an Action within 30 days from the date on the Contractor’s Notice of Action;
(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 shall file the Appeal on or before the later of the following:
(1) within 10 days of the Notice of Action; or
(2) the intended effective date of the Contractor’s proposed Action.
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8.4.4 Procedures for an Expedited Appeal
(A) When an Enrollee or provider requests an expedited resolution of an Appeal, the Contractor shall inform the Enrollee or provider of the limited time available for the Enrollee to present evidence and allegations of fact or law in person and in writing.
(B) The Contractor shall ensure that punitive action is not taken against a provider who either requests an expedited resolution to an Appeal or supports an Enrollee’s Appeal.
(C) The Contractor shall give Enrollees any reasonable assistance in making an expedited appeal. Reasonable assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.
(D) The Contractor shall acknowledge receipt of the request for expedited Appeal resolution either orally or in writing and explain to the Enrollee the process that must be followed to resolve the Appeal.
(E) 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 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 (ii) an appeal that involved clinical issues.
8.4.5 Denial of a Request for Expedited Appeal Resolution
(A) If the Contractor denies a request for an expedited resolution of an Appeal, the Contractor shall:
(1) Adjudicate the Appeal using the standard time frame of no longer than 30 calendar days from the day the Contractor receives the Appeal, with a possible 14 calendar day extension for resolving the Appeal and Providing Notice of Appeal resolution to affected parties.
(2) Make reasonable effort to give the Enrollee prompt oral notice of the denial.
(3) Mail written notice within two calendar days explaining the denial, specifying the standard time frame that must be followed, and informing the affected parties that the Enrollee may file a Grievance regarding the denial of expedited resolution of an Appeal.
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8.4.6 Time Frame for Expedited Appeal Resolution and Notification
(A) The Contractor shall resolve each expedited Appeal and provide notice to affected parties as expeditiously as the Enrollee’s health condition requires, but no later than three working days after the Contractor receives the expedited Appeal request.
(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 there is need for additional information and how the delay is in the Enrollee’s interest (upon Department request).
(C) If the Contractor extends the timeframe and the extension was not requested by the Enrollee the Contractor shall give the Enrollee written notice of the reason for the delay.
8.4.7 Format and Content of Expedited Appeal Resolution Notice
(A) The Contractor shall make reasonable effort to provide oral notice of the expedited resolution in addition to providing a written Notice of Appeal Resolution.
(B) The Contractor shall provide a written notice of Appeal Resolution that meets the same format and content requirements found in Section 8.3.5 of this Contract.
8.4.8 Continuation of Disputed Services During the Expedited Appeals Process
(A) The Contractor shall continue the Enrollee’s disputed services during the expedited Appeal process if:
(1) the Action being appealed is to terminate, suspend or reduce a previously authorized course of treatment;
(2) the services were ordered by an authorized provider;
(3) the original period covered by the original authorization has not expired;
(4) the Enrollee or provider files the Appeal timely, which means filing the Appeal on or before the later of the following:
(i) within 10 days of the Contractor mailing the Notice of Action; or (ii) by the intended effective date of the Contractor’s proposed Action; and (5) the Enrollee requests continuation of disputed services in the Appeal request.
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8.4.9 Duration of Continued Disputed Services and Enrollee Responsibility
(A) If the Contractor continues the Enrollee’s disputed services, the Contractors hall continue the disputed services until one of the following occurs:
(1) the Enrollee withdraws the Appeal;
(2) ten days pass after the Contractor mails written Notice of Appeal Resolution that is adverse to the Enrollee and within that 10 day time period, and the Enrollee does not request a State Fair Hearing with continuation of disputed services until a State Fair Hearing decision is reached;
(3) a State Fair Hearing officer issues a hearing decision adverse to the Enrollee; or (4) the time period of service limits of a previously authorized service has been met.
(B) If the final resolution of the Appeal or State Fair Hearing is adverse to the Enrollee, that is, the decision upholds the Contractor’s Action, the Contractor may recover the cost of the disputed service furnished to the Enrollee while the Appeal or State Fair Hearing was pending to the extent they were furnished solely because they were furnished according to the requirements found in 8.4.8 of this Contract and in accordance with 42 CFR 431.230(b).
8.4.10 Reversed Appeal Resolutions
(A) If the Contractor or State Fair Hearing officer reverses an action to deny, limit, or delay services that were not furnished while the Appeal was pending, the Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires.
(B) If the Contractor or the 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 Contractor shall pay for those services in accordance with State policy and regulations.