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 documents and records, and any new or additional evidence considered, relied upon, or generated by the Contractor considered during the appeals process. The Contractor will provide this information to the member free of charge and sufficiently in advance of the resolution timeframes for the appeals as specified in 42 C.F.R. § 438.408 (b) and (c). Under certain circumstances, certain categories of medical records and other documents may not be available to the member based on the type of record including, but not limited to, mental health records; and (d) include, as parties to the appeal, the member and his or her representative, or the legal representative of a deceased member’s estate. The Contractor must resolve each grievance and provide written notice of the resolution as expeditiously as the member’s health condition requires but not to exceed ninety (90) calendar days from the date that the Contractor received the grievance. For resolution of each standard appeal, the Contractor must provide written notice of the disposition within thirty (30) calendar days from the time the Contractor receives the appeal. The timeframes for both grievances and appeals resolution may be extended by up to fourteen (14) calendar days if the member requests an extension or if the Contractor shows (to the satisfaction of EOHHS upon request) that there is need for additional information and how the delay is in the member’s best interest. If the Contractor extends the timeframes not at the request of the member, it must complete all the following: • Make reasonable efforts to give the member prompt oral notice of the delay; • Within two (2) calendar days, give members written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; • Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires. Each written notice of determination 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 members, the right to a next level appeal, inclusive of an external appeal at no cost to the member; the right to request a State Fair Hearing, and how to do so; the right to request to receive benefits while the hearing is pending, and how to make the request; and that the enrollee may not be held liable for the cost of those benefits if the hearing decision upholds the Contractor’s notice of adverse benefit determination. • Information on how to contact the Contractor either in writing or telephone regarding the appeal process. In the case that the Contractor fails to adhere to the notice and timing requirements in this section, the member is deemed to have exhausted the internal appeals process. The member may initiate a State Fair Hearing.
Appears in 2 contracts
Samples: Medicaid Program Agreement, Medicaid Rite Smiles Program Agreement
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-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 documents and records, and any new or additional evidence considered, relied upon, or generated by the Contractor considered during the appeals process. The Contractor will provide this information to the member free of charge and sufficiently in advance of the resolution timeframes for the appeals as specified in 42 C.F.R. § CFR 438.408 (b) and (c). Under certain circumstances, certain categories of medical records and other documents may not be available to the member based on the type of record including, but not limited to, mental health records; and (d) include, as parties to the appeal, the member and his or her representative, or the legal representative of a deceased member’s estate. The Contractor must resolve each grievance and provide written notice of the resolution as expeditiously as the member’s health condition requires but not to exceed ninety (90) calendar days from the date that the Contractor received the grievance. For resolution of each standard appeal, the Contractor must provide written notice of the disposition within thirty (30) calendar days from the time the Contractor receives the appeal. The timeframes for both grievances and appeals resolution may be extended by up to fourteen (14) calendar days if the member requests an extension or if the Contractor shows (to the satisfaction of EOHHS upon request) that there is need for additional information and how the delay is in the member’s best interest. If the Contractor extends the timeframes not at the request of the member, it must complete all the following: • Make reasonable efforts to give the member prompt oral notice of the delay; • Within two (2) calendar days, give members written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; • Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires. Each written notice of determination 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 members, the right to a next level appeal, inclusive of an external appeal at no cost to the member; the right to request a State Fair Hearing, and how to do so; the right to request to receive benefits while the hearing is pending, and how to make the request; and that the enrollee may not be held liable for the cost of those benefits if the hearing decision upholds the Contractor’s notice of adverse benefit determination. • Information on how to contact the Contractor either in writing or telephone regarding the appeal process. In the case that the Contractor fails to adhere to the notice and timing requirements in this section, the member is deemed to have exhausted the internal appeals process. The member may initiate a State Fair Hearing.
i. Expedited Resolution of Appeals The Contractor must also establish and maintain an expedited review process for appeals. An expedited review is permitted when the Contractor determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking time for a standard resolution could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function. Expedited appeals must be resolved within seventy-two (72) hours of receipt of the appeal. The member may submit a verbal request for an expedited resolution of appeal. The member does not need to follow an oral request for an expedited resolution of appeal with a written request. The Contractor must inform the member of the limited time available for the member to present evidence and allegations of fact or law, in person and in writing, in the case of an expedited resolution. The Contractor may extend the timeframe for an expedited appeal by fourteen (14) days if the member, the member’s representative or the provider request an extension or the Contractor can show (to the satisfaction of EOHHS, upon EOHHS’ request) that there is need for additional information and that the extension is in the member’s interest. If the Contractor extends the timeframes not at the request of the member, it must complete all the following: • Make reasonable efforts to give the member prompt oral notice of the delay; • Within two (2) calendar days give the member’s written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; • Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires. The Contractor must ensure that punitive action is not taken against a provider who requests an expedited resolution or who supports a member’s request. If the Contractor denies the request for an expedited appeal, it must transfer the appeal to the timeframe for standard resolution, make reasonable efforts to give the member prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice. In the case that the Contractor fails to adhere to the notice and timing requirements in this section, the member is deemed to have exhausted the internal appeals process. The member may initiate a State Fair Hearing. Each written notice of determination 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 members, the right to a next level appeal, inclusive of an external appeal at no cost to the member; the right to request a State Fair Hearing, and how to do so; the right to request to receive benefits while the hearing is pending, and how to make the request; and that the enrollee may not be held liable for the cost of those benefits if the hearing decision upholds the Contractor’s notice of adverse benefit determination. • Information on how to contact the Contractor either in writing or telephone regarding the appeal process.
Appears in 1 contract
Samples: Medicaid Agreement
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-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 documents and records, and any new or additional evidence considered, relied upon, or generated by the Contractor considered during the appeals process. The Contractor will provide this information to the member free of charge and sufficiently in advance of the resolution timeframes for the appeals as specified in 42 C.F.R. § 438.408 (b) and (c). Under certain circumstances, certain categories of medical records and other documents may not be available to the member based on the type of record including, but not limited to, mental health records; and (d) include, as parties to the appeal, the member and his or her representative, or the legal representative of a deceased member’s estate. The Contractor must resolve each grievance and provide written notice of the resolution as expeditiously as the member’s health condition requires but not to exceed ninety (90) calendar days from the date that the Contractor received the grievance. For resolution of each standard appeal, the Contractor must provide written notice of the disposition within thirty (30) calendar days from the time the Contractor receives the appeal. The timeframes for both grievances and appeals resolution may be extended by up to fourteen (14) calendar days if the member requests an extension or if the Contractor shows (to the satisfaction of EOHHS upon request) that there is need for additional information and how the delay is in the member’s best interest. If the Contractor extends the timeframes not at the request of the member, it must complete all the following: • Make reasonable efforts to give the member prompt oral notice of the delay; • Within two (2) calendar days, give members written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; • Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires. Each written notice of determination 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 members, the right to a next level appeal, inclusive of an external appeal at no cost to the member; the right to request a State Fair Hearing, and how to do so; the right to request to receive benefits while the hearing is pending, and how to make the request; and that the enrollee may not be held liable for the cost of those benefits if the hearing decision upholds the Contractor’s notice of adverse benefit determination. • Information on how to contact the Contractor either in writing or telephone regarding the appeal process. In the case that the Contractor fails to adhere to the notice and timing requirements in this section, the member is deemed to have exhausted the internal appeals process. The member may initiate a State Fair Hearing.
i. Expedited Resolution of Appeals The Contractor must also establish and maintain an expedited review process for appeals. An expedited review is permitted when the Contractor determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking time for a standard resolution could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function. Expedited appeals must be resolved within seventy-two (72) hours of receipt of the appeal. The member may submit a verbal request for an expedited resolution of appeal. The member does not need to follow an oral request for an expedited resolution of appeal with a written request. The Contractor must inform the member of the limited time available for the member to present evidence and allegations of fact or law, in person and in writing, in the case of an expedited resolution. The Contractor may extend the timeframe for an expedited appeal by fourteen (14) days if the member, the member’s representative or the provider request an extension or the Contractor can show (to the satisfaction of EOHHS, upon EOHHS’ request) that there is need for additional information and that the extension is in the member’s interest. If the Contractor extends the timeframes not at the request of the member, it must complete all the following: • Make reasonable efforts to give the member prompt oral notice of the delay; • Within two (2) calendar days give the member’s written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; • Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires. The Contractor must ensure that punitive action is not taken against a provider who requests an expedited resolution or who supports a member’s request. If the Contractor denies the request for an expedited appeal, it must transfer the appeal to the timeframe for standard resolution, make reasonable efforts to give the member prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice. In the case that the Contractor fails to adhere to the notice and timing requirements in this section, the member is deemed to have exhausted the internal appeals process. The member may initiate a State Fair Hearing. Each written notice of determination 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 members, the right to a next level appeal, inclusive of an external appeal at no cost to the member; the right to request a State Fair Hearing, and how to do so; the right to request to receive benefits while the hearing is pending, and how to make the request; and that the enrollee may not be held liable for the cost of those benefits if the hearing decision upholds the Contractor’s notice of adverse benefit determination. • Information on how to contact the Contractor either in writing or telephone regarding the appeal process.
Appears in 1 contract
