405 Ind. Admin. Code 14-2-58

Current through October 9, 2024

Section 405 IAC 14-2-58 - Grievances and appeals

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 4-21.5-3-33; IC 12-15-28; IC 12-15-44.5; IC 12-17.6-2; IC 27-8-29-12; IC 27-13-10.1-1

Sec. 58.

(a) An MCO shall operate a grievance and appeals system that includes at least:

(1) a grievance process;

(2) expedited review procedures;

(3) access to an external grievance procedure;

(4) an appeals process; and

(5) access to the state's fair hearing system prescribed in 405 IAC 1.1.

(b) An MCO shall operate the grievance process in subsection (a)(1) under the following requirements and time frames:

(1) Members must be allowed to file grievances orally or in writing under 42 CFR 438.402.

(2) Members may file a grievance regarding any matter other than those meeting the definition of an adverse benefit determination or adverse action.

(3) Grievances may be filed at any time after the matter related to the grievance occurs.

(4) The MCO shall acknowledge receiving each grievance within three (3) business days. Acknowledgement is not required to be written unless requested by the member; however, if the member requests written acknowledgement, the acknowledgement must be made within five (5) business days after receiving request.

(5) The MCO shall make a decision on nonexpedited grievances as quickly as possible, but not more than thirty (30) calendar days after receiving a grievance. This time frame may be extended up to fourteen (14) calendar days if additional time is needed to resolve the matter. If the time frame is extended, for an extension not requested by the member, the MCO shall give the member written notice of the reason for the delay. The MCO shall give the member written notice of any extension within two (2) calendar days after the extension, including the:

(A) reason for the extension; and

(B) member's right to file a grievance if they disagree with the extension.

(6) The MCO shall provide an expedited grievance review, which shall be resolved within forty-eight (48) hours after it is received, on member request, or, if following the resolution time frame of thirty (30) calendar days may seriously jeopardize the member's:

(A) the life or health; or

(B) ability to regain maximum function.

(7) If the MCO denies a request for an expedited grievance review under subdivision (6), they shall:

(A) transfer the grievance to the standard grievance time frame;

(B) make a reasonable effort, including a phone call to the member, to provide the member with prompt oral notice of the denial; and

(C) follow up with a written notice to the member within two (2) calendar days.

(8) The MCO shall respond in writing to a member within five (5) business days after resolving a grievance or an expedited grievance. The resolution notice must include:

(A) notice of the member's right to file an appeal;

(B) the process for requesting an appeal;

(C) the expedited review options;

(D) the right to continue benefits during the appeal, as long as the request complies with the timeliness standards at 405 IAC 1.1;

(E) an explanation that the member may have to pay for care received if an adverse appeal decision is made; and

(F) for grievances related to a member's request to change MCOs, information on how to request a plan change.

(c) Under IC 27-13-10.1-1 and IC 27-8-29-12, an MCO shall maintain an external grievance procedure for resolving decisions related to:

(1) an adverse utilization review determination;

(2) an adverse determination of medical necessity; or

(3) a determination that a proposed service is experimental or investigational, which is operated under the following requirements and time frames:

(A) Members must first finish the MCO's grievance and appeals process.

(B) An external review under this subsection does not inhibit or replace the member's right to appeal an MCO decision to a state fair hearing.

(C) A member may seek external review by an independent review organization, and that process may run concurrently with a state fair hearing.

(D) Within one hundred twenty (120) calendar days after the date of the MCO's decision on the member's appeal, a member, or a member's representative, may file a written request for reviewing the MCO's decision by an independent review organization.

(E) An independent review organization shall render a decision to uphold or reverse the MCO's decision within seventy-two (72) hours for an expedited appeal, or fifteen (15) business days for a standard appeal. The determination made by the independent review organization is binding on the MCO.

(d) An MCO shall operate the appeals process in subsection (a)(4) under the following requirements and time frames:

(1) A member, and under 42 CFR 438.402, a provider acting on behalf of the member and with the member's written consent, shall have sixty (60) calendar days after the date of an adverse benefit determination notice to file an appeal.

(2) Under 42 CFR 438.406, the MCO shall ensure oral requests seeking to appeal an adverse benefit determination are treated as appeals.

(3) The MCO shall acknowledge receiving each standard appeal within three (3) business days.

(4) The MCO shall make a decision on standard, nonexpedited appeals within thirty (30) calendar days after reviewing the appeal. This time frame may be extended up to fourteen (14) calendar days under 42 CFR 438.408(c). If the time frame is extended, for an extension not requested by the member, the MCO shall give the member written notice of the reason for the delay.

(5) The MCO shall maintain an expedited review process for appeals, which provides for resolution within forty-eight (48) hours after receiving it, unless this time frame is extended under 42 CFR 438.408(c), when the MCO or member's provider determines that pursuing the standard appeals process may seriously jeopardize the member's life, health, or their ability to attain, maintain, or regain maximum function.

(6) Under 42 CFR 438.410, if the MCO denies the request for an expedited resolution of a member's appeal under subdivision (5), the MCO shall:

(A) transfer the appeal to the standard thirty (30) calendar day time frame;

(B) give the member written notice of the denial within two (2) days after the expedited appeal request; and

(C) make a reasonable attempt to give the member prompt oral notice, including a phone call to the member.

(7) Under 42 CFR 438.408, written notice of appeal disposition is given within five (5) business days after resolution to the member and, where appropriate, the provider. For an expedited resolution notice, the MCO shall also make reasonable efforts to provide oral notice. The written notice of the resolution must include:

(A) the results of the resolution;

(B) the date the resolution was completed; and

(C) for appeals not resolved wholly in favor of the member:

(i) the right to request an external grievance as detailed in subsection (c) and state fair hearing;

(ii) the procedures and how to request an external grievance or State fair hearing;

(iii) the right to request to receive benefits while the hearing is pending, including instructions on how to make the request;

(iv) notification that the member may be held liable for the cost of those benefits if the state hearing upholds the MCO's adverse benefit determination; and

(v) for appeals related to a member's request to change MCOs, information on how to request a just cause plan change.

(e) If the office, as defined at 405 IAC 1-1-1(12), takes an adverse action an individual or entity believes was erroneous, the individual or entity may request an administrative hearing under 405 IAC 1.1, which is governed by the procedures and time limits set forth in 405 IAC 1.1.

(f) A member who believes an MCO has taken an erroneous action must first complete the MCO's internal appeals procedure under subsection (d) before requesting an appeal with the office.

(g) After completing an MCO's internal appeals procedures, a member may request an administrative hearing under 405 IAC 1.1 not later than the time frame set forth in 405 IAC 1.1-1-3 after the date the MCO resolves of the appeal.

(h) Requests made under subsection (g) are governed by the procedures and time limits set forth in 405 IAC 1.1.

405 IAC 14-2-58

Office of the Secretary of Family and Social Services; 405 IAC 14-2-58; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA