1. ENROLLEE DUE PROCESS for Medicaid Managed CARE 42 CFR § 438 et seq.
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2. Utilization Management under Managed Care
Coverage and Authorization of Services. 42 CFR
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)
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3. 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
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4. 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
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5. Managed Care Due Process System Overview
Grievance System. 42 CFR
3 Levels:
Grievance Process
Conducted by LME/MCO
Called “Grievance” in North Carolina
Appeal Process
Called “Reconsideration” in North Carolina
State Fair Hearing
Hearing is conducted by the Office of Administrative Hearing
Called “Appeal” in North Carolina
Federal
North Carolina
Grievance
Appeal
Reconsideration
State Fair Hearing
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6. 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
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7. 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 (b).
42 CFR
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8. Appeal Process (“Reconsideration”) cont’d
Appeal means a request for review of an action (42 CFR )
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 appeal CFR
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9. Action Notices
Action Notices include both Initial Action Notice and Reconsideration Review Decisions
Action Notices must include the information required by 42 CFR § (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
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10. 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
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11. Primary NC law governing enrollee appeals of LME/MCO actions
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.
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12. 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
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13. State Fair Hearing (“Appeal”)
Two Phases:
Mediation
Office of Administrative Hearings (OAH) Proceeding
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14. Enrollee, his/her representative, sometimes attorney
Mediation
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
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15. Conducted by an administrative law judge (ALJ)
OAH
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
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16. Continuation of Benefits
Maintenance of Service (MOS) does NOT apply to managed care
*** CFR 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”).
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17. 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
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18. 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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19. Questions
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