Subsection 144-101-II-113.10 - DENIAL OF SERVICES, COMPLAINT PROCEDURES, AND MEMBER APPEAL RIGHTS113.10-1.Denial of ServicesA. The Broker may deny a trip or immediately discontinue a trip for any individual under the following circumstances: 1. The individual is found to be ineligible for NET services on the basis of the information provided and available to the Broker, including: a. The individual is not MaineCare eligible;b. The individual is not going to a covered MaineCare service; orc. The individual is not medically eligible for the coveredMaineCare service 2. The individual fails to request a transportation 2 business days in advance of the covered MaineCare service appointment without good cause. For purposes of this section, "good cause" can be established by factors such as: a. The imminent availability of an appointment with a specialist when the next available appointment would require a delay of two weeks or more; b. The result of administrative or technical delay caused by the Broker and requiring that an appointment be rescheduled;c. The need forurgent care; ord. The need for post-surgical and/or medical follow up care specified by a health care provider to occur in fewer than 48 hours;3. Or, the individual has other transportation resources available.B. A Broker may not deny or refuse to arrange NET services due to Member behavior. The Broker may at its discretion use a less cost effective mode of transportation if it determines it is necessary based on a Member's conduct. This alternate transportation must still be medically appropriate.C. Brokers may not discriminate against Members based upon political affiliation, religion, race, color, gender, physical or mental handicap, age, or national origin, or membership in any class protected under federal or state law.D. Notice of Denial of Services Following a denial of services to a Member, the Broker must notify the Member in writing within seventy-two (72) hours on a form approved by the Department. The written notice must include:
1. The Member's name, address, and MaineCare ID number at the head of the letter;2. The date of the letter;3. Notice that Appeals must be filed within 60 days of the date of the written notification;4. The date the transportation request was made by the Member (not the date of service, which may be different);5. The nature of the transportation request, including the destination, the type of transportation requested, the date and time of the medical appointment, and the type of medical service;6. The reason(s) the request was denied, including such things as: a) other verification that was done such as checking to see if there was an appointment scheduled with the medical provider, b) the Member had other transportation available to them; c) the transport was not to a covered medical service;7. The Member's right to choose to file an Appeal either with the Broker, or to appeal directly to the Department and proceed with the Fair Hearing process, pursuant to Chapter I Section 1 of the MaineCare Benefits Manual;8. Notice that if the Member chooses to file an appeal with the Broker, the Member must sign a written waiver that he or she understands that the right to receive a final decision after a Department administrative hearing, within 90 days of filing the Appeal, is waived. The notice must also inform the Member that at any point during the Broker appeal process, the Member may choose instead to file an appeal with the Department, and on the date the Member does so, the 90 day time period for the Department to render a final decision begins.9. If the Member chooses to file an Appeal with the Department and proceed to a Fair Hearing, a. The Member's right to obtain legal assistance for the Fair Hearing and a list of those organizations that may be able to provide free legal assistance to the Member; b. The Member's right to bring representation to assist the Member with the Fair Hearing; and c. The Member's right to bring witnesses to confront and cross examine any witnesses that are adverse to the Member at the Fair Hearing10. The circumstances under which the Member has a right to continuation of NET services pending outcome of the Appeal process and how the Member can request that benefits be continued, and the time frame for the request; and 11. A notice that if benefits are continued, and if the Broker's denial of services is upheldat the Department Fair Hearing, the Broker may not attempt to recover from the Member the cost of the NET services furnished.113.10-2 Broker Complaint ProceduresA. Complaints: Acomplaint is an expression of discontent with NET services that does not rise to the level of an appeal and for which the complainant has no appeal rights. Complaints must be registered with the Broker, either in writing or orally, by Members or their representatives, Transporters, or the public.B. Complaint Procedure: The Broker shall implement a Complaint Procedure. The Broker shall respond to all Complaints in a timely fashion and in accordance with its Complaint Procedure. There are no administrative hearing rights for Complaints.C. Reports: Brokers must report all Complaints and their resolutions to the Department. Brokers must retain all records of Complaints and their resolutions. 113.10-3 Appeal ProceduresFollowing the denial, termination, reduction, or suspension of services under Section 113, a Member has the option to appeal to either the Department or to the Broker. The Department's Appeals process involves a right to a fair hearing, whereas the Broker's Appeals process does not.
A. Appeal Defined: 1. A written request from a Member to the Department requesting a hearing regarding the denial, termination, reduction, or suspension of eligibility of services, made pursuant to Chapter Section 1.22 of the MBM; OR
2. A written request from a Member to a Broker requesting relief from the denial, termination, reduction, or suspension of eligibility of servicesB. Broker Appeals Process 1. Each Broker shall establish a Broker appeal process, which must be approved by the Department. 2. The Broker shall resolve all Broker appeals, in writing, within 60 days of a Member's request for the Broker appeal.3. The Broker shall send a copy of the Broker appeal resolution to the Department.4. If a Member is dissatisfied with the outcome of the Broker's Appeal process, the Member may file an Appeal with the Department.C. Department Fair Hearing Appeals 1. The Department Fair Hearing Appeal process is set forth in the MaineCare Benefits Manual, Ch. 1, Sec. 1; 2. The Broker shall attend fair hearings, if requested by the Department, and shall defend its decisions and otherwise assist the Department at its request, including providing copies of all documentation requested by the Department. It is essential that thorough documentation is available to support any testimony or respond to issues under investigation in the fair hearing.D. Timing of Appeals Should the Member choose to file an appeal with the Broker, the Member waives the right to receive a final decision after a Department administrative hearing within 90 days of filing the Appeal. However, at any point during the Broker appeal process, the Member may choose instead to file an appeal with the Department, and on the date the Member does so, the 90 day time period for the Department to render a final decision begins.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-113, subsec. 144-101-II-113.10