Section 441.73.12. Appeal of managed care organization actions.

The managed care organization shall have written appeal policies and procedures for an enrollee, or an enrollee’s authorized representative, to appeal a managed care organization action. The policies must address contractual requirements and federal funding requirements, including 42 CFR 438.400(b) as amended to October 16, 2015.

         73.12(1) Managed care organization appealable actions. Managed care organization actions that may be appealed include:

            a.               Denial or limited authorization of a requested service, including the type or level of service.

            b.               Reduction, suspension, or termination of a previously authorized service.

            c.               Denial, in whole or in part, of payment of service.

            d.               Failure to provide services in a timely manner as defined by the department.

            e.               Failure of the managed care organization to act within the required time frames set forth in federal funding requirements, including 42 CFR 438.408(b) as amended to October 16, 2015.

            f.                For a resident of a rural area that has only one appropriate provider of a needed service, the denial of an enrollee’s request to exercise the enrollee’s right to obtain services outside of the MCO’s network.

         73.12(2) Appeal process. The managed care organization appeal process shall be approved by the department and shall:

            a.               Allow for the appeal request to be submitted in writing or verbally. If the request is submitted verbally, it must be followed up with a written submission.

            b.               Require acknowledgment of the receipt of a request for an appeal within three working days.

            c.               Allow for participation by the enrollee and the provider.

            d.               Provide for resolution of nonexpedited appeals to be concluded within 45 calendar days of receipt of the request unless an extension is requested.

            e.               Provide for resolution of expedited appeals where the standard time period could seriously jeopardize the member’s health or ability to maintain or regain maximum function to be within three business days of receipt of the notice pursuant to federal funding requirements, including 42 CFR 438.402 as amended to October 16, 2015.

            f.                Ensure that the review will be made by qualified professionals who were not involved with the original action.

            g.               Ensure issuance of a notice of decision for each appeal. These notices shall contain the member’s appeal rights with the department and shall contain an adequate explanation of the action taken and the reason for the decision.

[ARC 2358C, IAB 1/6/16, effective 1/1/16]