Enrollee due process for medicaid managed care 42 cfr 438 et seq
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ENROLLEE DUE PROCESS for Medicaid Managed CARE 42 CFR § 438 et seq. Utilization Management under Managed Care. Coverage and Authorization of Services . 42 CFR 438.210 LME/MCO may place appropriate limits on services: based on established criteria, medical necessity

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Enrollee due process for medicaid managed care 42 cfr 438 et seq

ENROLLEE DUE PROCESS

for

Medicaid Managed CARE

42 CFR § 438 et seq.


Utilization management under managed care
Utilization Management under Managed Care

  • Coverage and Authorization of Services. 42 CFR 438.210

  • LME/MCO may place appropriate limits on services:

    • based on established criteria, medical necessity

    • for the purposes of utilization control

    • No more restrictive than DMA policy & NC State Plan

  • Written Policies and Procedures

  • Consistent Application

  • Notice Requirements (DMA standardized letters)


Service requests in managed care
Service Requests in Managed Care

  • Managed care does not utilize different types of service requests

    • Fee-for-service utilizes initial and concurrent prior approval requests, each with different implications and requirements

  • Each service request must be approved or denied

  • Denials must be appropriately noticed, including appeal (“reconsideration”) instructions

    • Any “action,” can be appealed

  • Approvals must be noticed and a service authorization issued

  • Upon expiration of the service authorization, a new service request must be submitted and the process starts over


Timeframes for responding to service requests
Timeframes for Responding to Service Requests

  • Standard. Within 14 calendar days following receipt of the service request

    • Can be extended 14 additional calendar days if additional information is required to make the decision or if enrollee/provider request

  • Expedited. Within 3 working days following receipt of the service request

    • Required when the standard timeframe seriously jeopardizes the enrollee's life or health or ability to attain, maintain, or regain maximum function

    • Can be extended 14 additional calendar days if additional information is required to make the decision

      42 CFR 438.210


Managed care due process system overview
Managed Care Due Process System Overview

  • Grievance System. 42 CFR 438.402

  • 3 Levels:

    • Grievance Process

      • Conducted by LME/MCO

      • Called “Grievance” in North Carolina

    • Appeal Process

      • Conducted by LME/MCO

      • Called “Reconsideration” in North Carolina

    • State Fair Hearing

      • Hearing is conducted by the Office of Administrative Hearing

      • Called “Appeal” in North Carolina


Grievance process grievance
Grievance Process (“Grievance”)

  • Grievance means an expression of dissatisfaction about any matter other than an “action”

  • Conducted by the LME/MCO

  • Possible subjects for grievances include:

    • quality of care or services provided

    • rudeness of a provider or employee

    • failure to respect a enrollee’s rights

    • SIS evaluation results

  • Monitored by DMA

    42 CFR 438.400


Appeal process reconsideration
Appeal Process (“Reconsideration”)

  • Only “actions” can be appealed:

    • denial of a service request

    • limited authorization of a service request

    • reduction, suspension, or termination of a previously authorized service – i.e., changes to a current, unexpired service authorization

    • Denial of payment for a service

    • Failure to authorize or deny a service request in a timely manner

    • Failure to act within the time frames required by 42 CFR 438.408(b).

      42 CFR 438.400


Appeal process reconsideration cont d
Appeal Process (“Reconsideration”) cont’d

  • Appeal means a request for review of an action (42 CFR 438.400)

  • Called “Reconsideration” in NC

  • Conducted by the LME/MCO

  • Must be decided by somebody other than the individual(s) who made the decision to take the action being appealed

    • Independent reviewers

  • “Reconsideration” over clinical actions must be decided by appropriate clinicians

  • Can be filed in writing or orally (oral request must be followed by a written, signed request)

  • Must allow the enrollee a reasonable opportunity to present evidence and allegations of fact or law

  • Must allow the enrollee to examine his/her medical records and the documents considered during the appeal42 CFR 438.406


Action notices
Action Notices

  • Action Notices include both Initial Action Notice and Reconsideration Review Decisions

  • Action Notices must include the information required by 42 CFR § 438.404(b)

  • Action Notices must include the reason for the decision:

    • The Policy/Waiver language that requires the Action

    • Why the medical information submitted does not meet Policy/Waiver criteria

    • If EPSDT applies, why the request is not medically necessary or otherwise approvable under EPSDT

    • A link to the applicable Policy/Waiver


State fair hearing appeal
State Fair Hearing (“Appeal”)

  • Enrollees must exhaust the Appeal Process (“Reconsideration”) before accessing State Fair Hearing

  • In North Carolina, the State Fair Hearing is called an “Appeal” and utilizes the Administrative Hearings procedure pursuant to G.S. § 150B & 108D

    • Applies to any appeal (“reconsideration”) not decided wholly in favor of the enrollee

    • State Fair Hearing process controlled by state law and rules

    • LME/MCO is the party to the State Fair Hearing

      42 CFR 438.408


N c g s 108d
N.C.G.S. § 108D

  • Primary NC law governing enrollee appeals of LME/MCO actions

  • OAH does not have jurisdiction except as provided by § 108D

  • The LME/MCO is the Respondent. DMA may move to intervene or the LME/MCO/Enrollee may move to join DMA.

  • OAH has 55 days from the date of the appeal to hear the case.


Timeframes for grievance system decisions
Timeframes for Grievance System Decisions

  • Grievances: 90 days

  • Appeals

    • Enrollee has 30 days to request an appeal (“reconsideration”) of a LME/MCO action

    • Standard: 45 days

    • Expedited: 3 working days

  • Timeframes to decide both grievances and appeals (both standard and expedited) may be extended up to 14 calendar days under certain circumstances.

  • State Fair Hearing

    • Any appeal (“reconsideration”) not decided wholly in favor of the enrollee, must include notice of State Fair Hearing (“appeal”) rights

    • Enrollee has 30 days to request State Fair Hearing from the date of the appeal (“reconsideration”) decision

    • After 30 days, the LME/MCO appeal (“reconsideration”) decision becomes final

      42 CFR 438.408


State fair hearing appeal1
State Fair Hearing (“Appeal”)

  • Two Phases:

    • Mediation

    • Office of Administrative Hearings (OAH) Proceeding


Informal

Telephonic

Enrollee, his/her representative, sometimes attorney

LME/MCO clinical team

Confidential

Voluntary

If no resolution is reached, appeal moves forward

Conducted by the Mediation Network of North Carolina, although OAH will initiate and monitor process

Mediation


Conducted by an administrative law judge (ALJ)

Pretrial motions, discovery, etc.

Telephonic or in person hearing

Enrollee, witnesses, and attorney

LME/MCO attorney and witnesses

Exhibits should be exchanged 5 days in advance

Testimony, cross examination, evidence, etc.

Following the hearing, the ALJ makes a decision and forwards his/her decision to the LME/MCO and Enrollee

Further appeal is in Superior Court

OAH


Continuation of benefits
Continuation of Benefits

  • Maintenance of Service (MOS) does NOT apply to managed care

  • *** CFR 438.420 Continuation of benefits while the LME/MCO appeal and the State fair hearing are pending

  • Does not apply when there is no service authorization or a previously issued service authorization has expired

  • Applies when the LME/MCO makes changes to a current, unexpired service authorization (i.e., a reduction, suspension, or termination)

  • Applies during the Appeal Process (“reconsideration”) and State Fair Hearing (“appeal”).


Continuation of benefits cont d
Continuation of Benefits cont’d

  • The LME/MCO must continue the service if all of the following are met:

    • The appeal (“reconsideration”) is timely requested

    • The appeal (“reconsideration”) involves the termination, suspension, or reduction of a currently authorized service

    • The service was ordered by an authorized provider

    • The current service authorization has not expired

    • The enrollee requests a continuation of the service

  • So long as all the criteria continue to be met, service continued during the Appeal Process (“reconsideration”) must also be continued during the State Fair Hearing (“appeal”)

    42 CFR 438.420


Continuation of benefits cont d1
Continuation of Benefits cont’d

  • The service must continue until either:

    • The enrollee withdraws the appeal (“reconsideration”)

    • Ten days after the appeal (“reconsideration”) decision is made, unless the enrollee requests a State Fair Hearing within those 10 days.

    • A State Fair Hearing decision is made against the enrollee

    • The service authorization expires

  • If the final appeal (“reconsideration”) and/or State Fair Hearing decision is against the enrollee, the enrollee may be responsible for the cost of the services furnished to the enrollee during the appeal process (“reconsideration”) and/or State Fair Hearing.



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