Health/Dental Plan Grievance and Appeals Process. The Contractor’s policies and procedures for processing grievances must permit a member, provider or authorized representative, acting on behalf of the member and with the member’s written consent, to file a grievance with the Contractor at any time. The timeframe for resolution is ninety (90) calendar days from receipt of the grievance as provided in Rhode Island Medicaid Managed Care Grievance and Appeals Process. The Contractor’s policies and procedures for processing appeals must permit a member, provider or authorized representative acting on behalf of the member and with the member’s written consent, to file an appeal of a notice of adverse benefit determination within sixty (60) calendar days from the date on the Contractor’s notice. In handling grievances and appeals, the Contractor must: • Give members any reasonable assistance in completing forms and taking procedural steps, including, but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. • Allow members to file grievance or appeal verbally which must be confirmed in writing to establish the earliest possible filing date unless there is a request for an expedited appeal. • Acknowledge each grievance and appeal within five (5) calendar days. • Ensure that the individuals who make decisions on grievances and appeals are individuals who were not involved in any previous level of review or decision-making and they are not subordinates of any such individual. • Ensure that decision makers on grievance and appeals are health care professionals who have appropriate clinical expertise, as determined by the State, in treating the member’s condition or disease if they are involved in deciding on any of the following: (a) an appeal of a denial that is based on lack of medical necessity, (b) a grievance regarding denial of expedited resolution of an appeal; or (c) a grievance or appeal that involves clinical issues • Ensure that that decision makers on grievances and appeals consider all comments, documents, records, and other information submitted by the enrollee or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination. • Provide the member a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. • Provide the member and his or her representative the member case file, including medical records, other...
