Iowa Admin. Code r. 441-73.12

Current through Regsiter Vol. 46, No. 26, June 12, 2024

Rule 441-73.12 - Appeal of MCP actions

The MCPs shall have written appeal policies and procedures for an enrollee, or an enrollee's authorized representative, to appeal an MCP action. The policies must address contractual requirements and federal funding requirements, including 42 CFR 438, Subpart F, as amended to July 19, 2022.

(1)MCP appealable actions. MCP 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 described by the department.

e. Failure to act within the required time frames set forth in federal funding requirements, including 42 CFR 438.408(b) as amended July 19, 2022.

f. For a resident of a rural area who 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.

g. The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.

(2)Appeal process. The MCP appeal process shall be approved by the department and shall:

a. Allow for the appeal request to be submitted in writing or verbally.

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 30 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 72 hours of receipt of the notice pursuant to federal funding requirements, including 42 CFR 438.402 as amended to July 19, 2022.

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.

Iowa Admin. Code r. 441-73.12

Adopted by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016

Amended by IAB March 14, 2018/Volume XL, Number 19, effective 2/14/2018

Amended by IAB April 5, 2023/Volume XLV, Number 20, effective 6/1/2023