Medicaid Appeals Process

Transcription

1 Medicaid Appeals Process Fee for Service and Managed Care Medicaid 69 Million People Covered Eligible Beneficiaries: Low income adults, children, pregnant women, elderly adults and people with disabilities ACA Expansion: 133 percent of the federal poverty level 32 States including DC 1

2 Appeals State Fair Hearings Prior Authorization Disputes Claims Disputes Fee for Service and Managed Care State Fair Hearings The State or local agency must send a notice at least 10 days before the date of action The agency must allow the applicant or beneficiary a reasonable time, not to exceed ninety (90) days from the date that notice of action is mailed, to request a hearing. 2

3 Reason for Hearing Any individual who requests it because he or she believes the agency has taken an action erroneously, denied his or her claim for eligibility or for covered benefits or services, or issued a determination of an individual's liability, or has not acted upon the claim with reasonable promptness including, if applicable An initial or subsequent decision regarding eligibility; A determination of the amount of medical expenses that an individual must incur in order to establish eligibility; or A determination of the amount of premiums and cost sharing charges; A change in the amount or type of benefits or services; or A request for exemption from mandatory enrollment in an Alternative Benefit Plan. Expedited Appeals The agency must establish and maintain an expedited fair hearing process for individuals to request an expedited fair hearing, if the agency determines that the time otherwise permitted could jeopardize the individual's life, health or ability to attain, maintain, or regain maximum function. The agency must take final administrative action within seven (7) working days after the agency receives a request for expedited fair hearing if the agency determines that the individual meets the criteria for an expedited fair hearing. 3

4 Maintaining Services If the agency sends the 10-day or 5-day notice as required and the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless It is determined at the hearing that the sole issue is one of Federal or State law or policy; and The agency promptly informs the beneficiary in writing that services are to be terminated or reduced pending the hearing decision. If the agency's action is sustained by the hearing decision, the agency may institute recovery procedures against the applicant or beneficiary to recoup the cost of any services furnished the beneficiary, to the extent they were furnished solely by reason of this section. Final Administrative Action Ordinarily, within 90 days from: The date the enrollee filed an MCO, PIHP, or PAHP appeal, not including the number of days the enrollee took to subsequently file for a State fair hearing; or For all other fair hearings, the date the agency receives a request for a fair hearing. 4

5 Expedited Decisions In the case of individuals granted an expedited fair hearing: For a claim related to eligibility, or any claim relating to a nursing facility, or related to preadmission and annual resident review, as expeditiously as possible and, effective no later than seven (7) working days after the agency receives a request for expedited fair hearing; or For a claim related to services or benefits as expeditiously as possible and no later than seven (7) working days; State agency send notice to beneficiary (mailed at least 10 days in advance of the date of intended action) Beneficiary requests hearing within reasonable time established by the state agency (at least 20 days and no more than 90 days from the date the notice was mailed) State option to provide a local level evidentiary hearing Local evidentiary hearing written decision to beneficiary 5

6 Hearing decision is favorable Hearing decision is adverse to the beneficiary, beneficiary can request a state fair hearing within 15 days of the decision State Fair Hearing Hearing decision is favorable Hearing decision is adverse, beneficiary may seek judicial review Florida Fair Hearings 6

7 Action In the case of a recipient receiving services through the fee-forservice (FFS) delivery system, any of the following: The reduction, suspension, or termination by the Agency of a previously authorized service, or The denial, in whole or in part, of a requested service or supplies by the Agency. Adverse Benefit Determination In the case of a MCO enrollee, any of the following: The denial, in whole or in part, of a requested service or supplies by the plan; The reduction, suspension, or termination by the plan of a previously authorized service; The failure of the plan to provide services in a timely manner as specified in the Agency s contract with the plan, or The denial by the plan of an enrollee s request to dispute a Florida Medicaid financial liability, including, copayments and coinsurance. 7

8 Hearing Request A clear, written or oral expression to the Agency requesting review of: An action; A plan appeal of an adverse benefit determination; A disenrollment denial, pertaining to the enrollee, or A matter within the fair hearing jurisdiction of the Agency. Reasons for Fair Hearing A FFS recipient who makes a hearing request regarding: The reduction, suspension, or termination by the Agency of a previously authorized service; The denial, in whole or in part, of a requested service or supply by the Agency, or The failure of the Agency to provide a timely Notice of Action (NOA) subsequent to the Agency s failure to provide all medically necessary services to the recipient with reasonable promptness. 8

9 Hearing Request for Managed Care A notice of plan appeal resolution indicating that the plan appeal did not result in the reversal of a prior denial of a new service, or the reduction, suspension, or termination of a previously authorized service; The failure of the plan to adhere to notice and timing requirements applicable to plan appeals; or The failure of the plan to timely notice the enrollee through a NABD (Notice of Adverse Benefit Determination), subsequent to the plan s failure to provide medically necessary services requested by the enrollee to the enrollee with reasonable promptness. Parties The parties to a fair hearing regarding FFS benefits are the FFS recipient and the Agency. The parties to a fair hearing regarding managed care benefits are the enrollee and the plan. Upon request by the Agency, the Agency may be granted party status by the Hearing Officer. The parties to a fair hearing regarding a disenrollment denial are the enrollee and the Agency. The parties to a fair hearing regarding a reimbursement request are the recipient and the Agency. The parties to any fair hearing are the recipient and the appropriate state agency or its designee. 9

10 Appearances, Authorized Representatives, and Withdrawal Recipients may represent themselves in a fair hearing, they may be represented by a non-attorney authorized representative, or, they may be represented by an attorney authorized to practice law in Florida retained by the recipient, or a person with authority to retain counsel for the recipient. Counsel representing a party in a fair hearing shall promptly file with the Office and serve on each other party a notice of appearance, which includes counsel s mailing address of record and address. Filing of a notice of appearance shall constitute acceptance of service at the address provided by counsel. Any person, including counsel or a recipient s provider, requesting a fair hearing on behalf of a recipient, or seeking to represent a recipient in a fair hearing, must provide and maintain with the Office: A written authorization signed by the recipient or by a person with legal authority to act on behalf of the recipient, designating the person as the recipient s authorized representative; and, A mailing address of record, and may designate an address with the Office. As set forth herein, counsel appearing on behalf of a recipient consents to service via . Upon motion, the Hearing Officer shall grant counsel of record or an authorized representative leave to withdraw from representation of a party for good cause shown. The motion shall contain the mailing address, address, if applicable, and telephone number of the party represented. 10

11 Requests for Fair Hearing Fair hearing requests made on or after March 1, 2017 must be directed to AHCA, who can be contacted at: Agency for Health Care Administration Medicaid Hearing Unit P.O. Box Ft. Myers, FL Telephone: (toll-free) Fax: A recipient may make a hearing request either orally or in writing. The Agency must receive the fair hearing request within ninety (90) days of the date a required NOA is sent to the recipient. The Agency may waive the ninety (90) day time limit for making a hearing request when: The Agency fails to send a timely NOA to the FFS recipient, or The Agency fails to act on a FFS recipient s specific request for benefits. An enrollee must initiate and complete a plan appeal before making a fair hearing request. The plan appeal is complete when: The enrollee receives from the plan a NPAR indicating the plan appeal was not resolved wholly in the enrollee s favor, or The plan fails to adhere to notice and timing requirements applicable to plan appeals. 11

12 An enrollee need not initiate and complete a plan appeal before making a fair hearing request if the request is based on a plan determination or NOA rendered before March 1, A fair hearing request by an enrollee must be received by the Agency within 120 days of the date the required NPAR is sent to the enrollee. In other instances where a recipient is entitled to a fair hearing, the hearing request must be received by the Agency within ninety (90) days of the date of the required time to provide a NOA, or such other time specified by law. Notice of Fair Hearing The Office shall provide each party with a written notice of fair hearing at least fourteen (14) days in advance of the fair hearing date. The recipient or enrollee may waive the fourteen (14) days advance notice requirement, upon written request. Each party shall comply with all prehearing instructions issued by the Office or a Hearing Officer. 12

13 Acknowledgement, Denial, and Dismissal of Fair Hearing Requests A Hearing Officer is authorized to deny or dismiss a request for a fair hearing for reasons consistent with this rule, including the following: The Office does not have jurisdiction over the subject matter of the fair hearing; The enrollee has not completed the plan appeal; A fair hearing request is untimely; A person other than the recipient makes a hearing request without also filing a written designation signed by the recipient authorizing the representation; The recipient: Files a written withdrawal of the fair hearing request, or Fails to appear at the scheduled fair hearing without good cause; The fair hearing is moot, or The sole issue is a federal or state law requiring an automatic change adversely affecting some or all recipients or enrollees. Hearing Officers A Hearing Officer shall be appointed by the Agency to preside over each fair hearing and must: Ensure that the fair hearing is conducted in a manner consistent with this rule and promotes the fair, just, and speedy resolution of the proceeding; Be impartial and was not involved in the initial determination giving rise to the fair hearing; and, Refrain from unilateral communications with a party or a party s representative regarding the substance of the issues presented in the fair hearing; if any such communication occurs, the Hearing Officer shall document the communication in the record of the fair hearing. The Hearing Officer shall have the authority to issue any and all orders and render rulings consistent with this rule. 13

14 Conduct of Hearing Hearings conducted pursuant to this rule are only open to the parties and their witnesses, unless authorized by the Hearing Officer and with the consent of the recipient or enrollee. Each fair hearing shall be a de novo, evidentiary proceeding, and shall be conducted in a manner that meets the requirements of this rule. Each fair hearing shall be conducted by telephone or in such manner as prescribed by the Hearing Officer. The Hearing Officer has the authority to swear witnesses and take their testimony under oath. Testimony taken by telephone or other telecommunications media does not require that a notary be present with the witness to administer the oath; however, the Hearing Officer must be satisfied as to the identity of the party or witness testifying. Each fair hearing shall be recorded. A copy of the recording shall be provided to the recipient or enrollee, upon request and free of charge. The recipient must have access to his or her entire case file including all medical records and any other documents and records considered or relied upon by a plan regarding a plan appeal, or by the Agency, whichever is applicable, during the course of the hearing. These materials shall be provided upon the recipient s request free of charge. When the plan is a party, it shall file with the Office or Hearing Officer all legal authorities, Florida Medicaid policies and regulations, and contractual provisions relied upon for its determination of any issues presented in the fair hearing. The enrollee must have access to this information during the course of the hearing. 14

15 Burden of Proof The burden of proof is on the party asserting the affirmative of an issue, except as otherwise required by statute. The burden of proof is on the Agency or plan, whichever is applicable, when the issue presented is the suspension, reduction, or termination of a previously authorized service. The burden of proof is on the recipient or enrollee, when the issue presented is the denial or a limited authorization of a service. The party with the burden of proof shall establish its position to the satisfaction of the Hearing Officer by a preponderance of the evidence. Enrollee/Recipient Rights The recipient or enrollee shall be entitled to: Introduce evidence relevant to the issues presented; Examine and rebut any evidence presented by another party through the introduction of rebuttal evidence, and examination and cross-examination of any witness; If documentary evidence is received in the form of a copy or excerpt, to compare the copy with the original, if available and to conduct cross-examination when such documents are made a part of the record; Call witnesses at the hearing; Cross-examine adverse witnesses; and, Impeach any witness. 15

16 Final Orders The Final Order shall be rendered within ninety (90) days of the date of the request for a fair hearing, unless the time period is waived by the recipient or extended by order of the Hearing Officer. The Final Order must be based exclusively on evidence introduced at the hearing and any post-hearing submission authorized by the Hearing Officer. Findings of fact shall be based upon a preponderance of the evidence, unless otherwise provided by statute, and shall be based exclusively on the evidence of record and on matters officially recognized. Fee for Service State Examples Texas Prior Authorization Appeals California TAR Appeals Massachusetts Claims Appeals Indiana Claims Appeals 16

17 Texas Fee for Service Prior Authorization Appeals Prior authorizations that are denied by Texas Medicaid and Healthcare Partnership (TMHP) can be resubmitted to the TMHP Prior Authorization Department with new or additional information for reconsideration. If the request is denied a second time, or if the provider has no new or additional information, the provider may file an Administrative Appeal to HHSC. Providers must include a copy of the denial letter. Document Requirements and Retention If information provided in the online request is insufficient to support medical necessity, TMHP Prior Authorization staff may ask the provider to submit additional paper documentation to support the medical necessity for the service being requested. It is strongly recommended that providers maintain a list that details the prior authorizations, including: Client s name Client s Medicaid number Date of service Provider Identifier Items submitted 17

18 Documentation requirements include, but are not limited to, the following: Documentation that supports the medical necessity for the service requested. Completion and retention in the client s medical record of all required prior authorization forms Adherence to signature and date requirements for prior authorization forms and other required forms that are kept in the client record, including the following: All prior authorization forms completed and signed before the online prior authorization request is made Original handwritten or electronic signatures (Stamped signatures and images of wet signatures are not accepted by Texas Medicaid.) A printed copy of the Online Request Form, which must be retained in the client s medical record Administrative Appeals An administrative or medical appeal must be: Submitted to HHSC Medicaid/CHIP Administrative Claim and Medical Appeals after the appeals process with the claims administrator or claims processing entity has been exhausted, and the documentation to the state must contain evidence of previous claims administrator or claims processing entity appeal dispositions: All correspondence and documentation from the provider to TMHP or the claims processing entity including copies of supporting documentation submitted during the appeal process. All correspondence from TMHP or the claims processing entity to the provider including TMHP s final decision letter or such from the claims processing entity. 18

19 A complete request and contain all of the information necessary for consideration and determination by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals, including a written explanation of the request for appeal and supporting documentation for the request: A written explanation specifying the reason/request for appealing the claim. Supporting documentation for the request. All R&S Reports identifying the claims/services in question. Identification of the incorrect information and the corrected information that is to be used to appeal the claim. A copy of the original claim, if available. Claim copies are helpful when the appeal involves medical policy or procedure coding issues. Also provide a corrected signed claim. Provider s internal notes and logs or ticket numbers from the TMHP Contact Center when pertinent (cannot be used as proof of timely filing). Memos from the state, TMHP, or claims processing entity indicating any problems, policy changes, or claims processing discrepancies that may be relevant to the appeal. Other documents, such as receipts (i.e., certified mail along with a detailed listing of the claims enclosed), in-service notes, minutes from meetings, if relevant to the appeals. Receipts can be helpful when the issue is late filing. Time Limits Received by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals within one hundred and twenty (120) days from the date of disposition by the claims administrator or claims processing entity as evidenced by the Remittance and Status report sent to providers. HHSC Claims Administrator Contract Management only reviews appeals that are received within eighteen (18) months from the date of service. All claims must be paid within twenty-four (24) months from the date of service. 19

20 California TAR Appeals Treatment Authorization Request (TAR) For services other than vision, the provider may submit a written appeal to the address below within one hundred and eighty (180) calendar days from the date of the original decision (TAR action date) by the Medi-Cal consultant. The Medi-Cal Clinical Assurance & Administrative Support Division (CAASD) handles the appeal process. Appeals submitted by fax are not permitted and will be rejected. The written appeal must be: Postmarked by the United States Postal Service, or Personally delivered to the Department of Health Care Services (DHCS) and date stamped upon receipt, or Labeled with the date deposited with a common carrier (e.g., UPS, FedEx) for delivery to DHCS 20

21 Contents of the Appeal The written appeal must include all of the following: A copy of the Adjudication Response (AR) indicating the TAR was denied or modified and the service type requested. The AR lists the status of all service line submitted on the TAR; Date(s) or service(s) in dispute; Reason the appeal should be granted; Medical records and any additional documentation that a provider submits to support the conclusion that services are medically necessary; and A new, completed paper TAR for the services appealed. Department Review The Department shall review the provider appeal and send a written decision, and the basis for that decision, to the provider: When the appeal decision is based on a review of documented medical necessity, the written decision shall be sent to the provider within 180 calendar days from the date of receipt by the Department. When the appeal decision is a denial based on failure to submit the appeal within 180 calendar days from the date of the decision on the original TAR, the written decision shall be sent to the provider within sixty (60) calendar days from the date of receipt by the Department. If a provider is not satisfied with the appeal decision, the provider may seek a judicial remedy pursuant to Section 1085 of the Code of Civil Procedure. 21

22 Massachusetts Fee for Service Claims Appeals All requests for appeals submitted to the MassHealth agency for review must be submitted electronically in a format designated by the MassHealth agency, unless the provider has been approved for an electronic claim submission waiver. To file an appeal with the MassHealth agency s Final Deadline Appeals Board, the provider must meet all of the following criteria. The provider must have submitted the original claim in a timely manner, all claims must be received by the MassHealth agency within ninety (90) days from the date of service or the date of the explanation of benefits from another insurer. The provider must have exhausted all available corrective actions outlined in the billing instructions provided by the MassHealth agency. The provider must file the appeal within thirty (30) days after the date on the remittance advice that first denied the claim for exceeding the final billing deadline. Claims for dates of service more than thirty-six (36) months after the date of service are not eligible for an appeal. The provider must demonstrate that the claim was, as a result of MassHealth agency error, denied or underpaid. 22

23 Accompanying Documentation Along with each appeal of a claim, the provider must submit the following information to substantiate the contention that the claim was, because of MassHealth agency error, denied or underpaid: A standard appeal form prescribed by the MassHealth agency or cover letter describing the nature of the MassHealth agency error that resulted in the denial or underpayment of the claim. The statement must include the provider name, provider ID/service location number, member name, member number, and date of service. Evidence of the claim's original, timely submission and resubmission, if applicable; A copy of the applicable page from each remittance advice on which the claim was previously processed; A copy of the remittance advice or electronic response that indicates that the final submission deadline has passed; An accurately completed electronic claim or a legible and accurately completed paper claim if the provider has received a waiver of the electronic submission requirement; and Any other documentation supporting the appeal. Request for an Adjudicatory Hearing A provider may submit a request for an adjudicatory hearing with a final deadline appeal if there is a dispute about a genuine issue of material fact. The request must include a statement indicating the specific reasons why a hearing should be conducted. The request must include the following information: A statement identifying the material facts in dispute; A summary of the evidence that the provider would offer at the hearing to support his or her contentions; and A statement explaining why the evidence could only be presented at a hearing. 23

24 Indiana Claims Appeals All provider claims for payment of services rendered as fee-for-service to IHCP members must be originally filed with Hewlett Packard Enterprise within twelve (12) months of the date of service. The following guidelines apply to administrative review and appeals related to fee-for-service claims. For Claim Denials Upon receipt of a claim denial, the provider must do the following: Review the claim and the denial reason code(s). If the provider cannot determine why the claim denied, the provider may contact Customer Assistance or submit a written inquiry to Hewlett Packard Enterprise using the IHCP Written Inquiry form (available on the Forms page at indianamedicaid.com) or a secure correspondence message (using the Claim Inquiry category) through the Provider Healthcare Portal at indianamedicaid.com. 24

25 For Paid Claims If a claim is filed timely and is paid, including claims partially paid or paid at zero, and the provider disagrees with the reimbursement, the provider should: Review the claim and the Remittance Advice (RA) information. The claim adjustment or void/replacement must be filed within sixty (60) days of notification of the claim s disposition. Notification is considered to be the date on the RA. After the provider has made reasonable attempts to correct or adjust a claim, if the provider remains dissatisfied with the reimbursement, the provider may submit a written request for administrative review stating why the provider disagrees with the claim payment amount. Filing an Administrative Review Request For reconsideration of an adjudicated claim, providers must file a written request for an administrative review of the claim. Write the request, including the reason for disagreement with the denial or the amount of reimbursement, using one of the following methods: Create a secure correspondence message on the Provider Healthcare Portal, using the Administrative Review Request category. Complete an IHCP Administrative Review Request form, available on the Forms page at indianamedicaid.com. Write a letter on letterhead stating the reason for disagreement with the denial or the amount of reimbursement and clearly note Administrative Review on the face of the letter. 25

26 Include all pertinent documentation supporting reconsideration with the secure correspondence, form, or letter. Document the unusual circumstances in which the provider believes the claim was coded correctly and would like a reconsideration of the NCCI editing. Document the reason for disagreement. Document the denial reason and the reason the payment is being disputed File the formal administrative review request within sixty (60) calendar days of notification of claim payment or denial from Hewlett Packard Enterprise. The date of notification is considered to be the date on the RA. Administrative Review Responses Providers will receive a written confirmation of receipt of their request for administrative review within ten (10) business days. Hewlett Packard Enterprise will respond to all administrative review requests within ninety (90) business days of receipt of the request, regardless of the decision to pay or deny the claim. Each denial decision is specific, detailed, and fully documented. If the administrative review response is unfavorable to the provider, the provider may file an appeal. 26

27 Appeals A provider must exhaust the formal administrative review process, as described in the preceding section, before filing an appeal. The provider must comply with all requests to submit information or additional documentation and must receive a final written administrative review decision. If all the procedures required for administrative review have been exhausted and the provider is still not satisfied with the determination, the provider can send a request for appeal under the provisions of 405 IAC The appeal request should include all pertinent facts, proof of actions taken to resolve the payment or denial, and any associated documentation. The IHCP must receive the appeal request within fifteen (15) business days after the provider receives the adverse administrative review decision notice on which the appeal is premised. If a provider elects to appeal, the provider must also file a statement of issues within forty-five (45) days of the date of the adverse administrative review determination. The statement of issues should be sent to the same address as the appeal request. Appeal proceedings will be conducted by a Family and Social Services Administration (FSSA)-appointed administrative law judge. An administrative law judge s adverse decision can be appealed by filing objections with the ultimate authority for the agency within fifteen (15) business days of receipt of the decision. An appellant can file a petition for judicial review if the appellant is not satisfied with the agency review decision. 27

28 Managed Care Managed Care Prior Authorization Standard authorization decisions. For standard authorization decisions, provide notice as expeditiously as the enrollee's condition requires and within Stateestablished timeframes that may not exceed fourteen (14) calendar days following receipt of the request for service, with a possible extension of up to fourteen (14) additional calendar days, if The enrollee, or the provider, requests extension; or The MCO justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee's interest. 28

29 Expedited Authorization Decisions If provider indicates that following the standard timeframe could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, the MCO must make an expedited authorization decision and provide notice as expeditiously as the enrollee's health condition requires and no later than seventy-two (72) hours after receipt of the request for service. The MCO may extend the seventy-two (72) hour time period by up to fourteen (14) calendar days if the enrollee requests an extension, or if the MCO justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee's interest. Outpatient Drugs All authorization determinations for prescriptions or over-the-counter drugs must be made no later than the following business day after the receipt of the request (24 hours). Any additional information needed must be requested within one business day of the initial request and it must be made no later than one business day after the receipt of the additional information. 29

30 Adverse Benefit Determination Following receipt of a notification of an adverse benefit determination by an MCO an enrollee has sixty (60) calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan. The enrollee may request an appeal either orally or in writing. Further, unless the enrollee requests an expedited resolution, an oral appeal must be followed by a written, signed appeal. An MCO s process for handling enrollee grievances and appeals of adverse benefit determinations must: Acknowledge receipt of each grievance and appeal. Ensure that the individuals who make decisions on grievances and appeals are individuals Who were neither involved in any previous level of review or decisionmaking nor a subordinate of any such individual. Who, if deciding any of the following, are individuals who have the appropriate clinical expertise, as determined by the State, in treating the enrollee's condition or disease. 30

31 Resolution Grievances and Appeals Standard resolution of grievances: For standard resolution of a grievance and notice to the affected parties, the timeframe is established by the State but may not exceed ninety (90) calendar days from the day the MCO receives the grievance. Standard resolution of appeals: For standard resolution of an appeal and notice to the affected parties, the State must establish a timeframe that is no longer than thirty (30) calendar days from the day the MCO receives the appeal. Expedited Resolution of Appeals Expedited resolution of appeals: For expedited resolution of an appeal and notice to affected parties, the State must establish a timeframe that is no longer than seventy-two (72) hours after the MCO receives the appeal. Extension of timeframes: The MCO may extend the timeframes by up to fourteen (14) calendar days if The enrollee requests the extension; or The MCO shows (to the satisfaction of the State agency, upon its request) that there is need for additional information and how the delay is in the enrollee's interest. 31

32 Action Following Denial of a Request for Expedited Resolution If the MCO denies a request for expedited resolution of an appeal, it must (1) Transfer the appeal to the timeframe for standard resolution. (2) If the MCO extends the timeframes not at the request of the enrollee, it must complete all of the following: Make reasonable efforts to give the enrollee prompt oral notice of the delay. Within two (2) calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. Continuation of Benefits Continuation of benefits. The MCO must continue the enrollee's benefits if all of the following occur: The enrollee files the request for an appeal timely within ten (10) days of notice; The appeal involves the termination, suspension, or reduction of previously authorized services; The services were ordered by an authorized provider; The period covered by the original authorization has not expired; and The enrollee timely files for continuation of benefits. 32

33 Content of Notice of Appeal Resolution The written notice of the resolution must include the following: The results of the resolution process and the date it was completed. For appeals not resolved wholly in favor of the enrollees The right to request a State fair hearing, and how to do so. The right to request and receive benefits while the hearing is pending, and how to make the request. That the enrollee may, consistent with state policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO s adverse benefit determination. External Medical Review. The State may offer and arrange for an external medical review if the following conditions are met. The review must be at the enrollee's option and must not be required before or used as a deterrent to proceeding to the State fair hearing. The review must be independent of both the State and MCO The review must be offered without any cost to the enrollee. The review must not extend any of the timeframes and must not disrupt the continuation of benefits. State Fair Hearing. The enrollee must request a State fair hearing no later than one hundred and twenty (120) calendar days from the date of the MCO s notice of resolution. 33

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