Section 471-37-005 - PARTICIPANT RIGHTS005.01 Written Explanation Upon enrollment, a PACE participant shall be informed, in writing, of his/her rights and responsibilities and all rules and regulations governing participation according to 42 CFR 460.110 and 460.112.
005.02 Grievance Process Upon enrollment and at least annually thereafter, the PACE organization supply participants written information about its grievance process. In the event of a grievance, the PACE organization shall:
1. Discuss with and provide to the participant in writing the specific steps, including timeframes for response, that will be taken to resolve the participant's grievance;2. Continue to furnish all required services to the participant during the grievance process.005.03 Appeal Processes for Non-Coverage or Non-Payment of a Service The PACE organization shall give enrolled participants written information on available appeal processes upon enrollment, at least annually thereafter, and whenever a participant takes action with respect to the PACE organization's non-coverage or non-payment of a service including denials, reductions, or terminations of services. (See section 37-002.04 of this chapter for appeals of denial of enrollment and section 37-006.04 of this chapter for appeals of involuntary disenrollments.)
37-005.03AAvailable Appeal Processes: 1. The PACE organization's internal appeal process.2. The SAA's appeal process (external appeal process).3. Medicare's appeal process through the Independent Review Entity (IRE) that contracts with CMS (external appeal process).37-005.03BPACE Organization Internal Appeal Process: Participants shall first access the PACE organization's internal appeal process prior to using the SAA's or Medicare's appeal process for all decisions pertaining to non-coverage of, or non-payment for, a service including denials, reductions, or terminations of services.37-005.03C PACE Organization Third Party Review: The PACE organization must appoint an appropriately credentialed and impartial third party who was not involved in the original action and who does not have a stake in the outcome of the appeal to review the participant's appeal. 37-005.03C1Notice of Internal Appeal Outcome: The PACE organization shall notify a participant of the outcome of his/her appeal in writing no later than 30 calendar days after the organization receives the verbal or written appeal, unless the appeal has been expedited as described in section 37-005.03C 2 of this chapter.37-005.03C2Expedited Appeal Process: A PACE organization shall have an expedited appeal process for situations in which the participant believes that his or her life, health, or ability to regain or maintain maximum function could be seriously jeopardized, absent provision of the services in dispute. 37-005.03C2aExpedited Appeal Notice: The PACE organization must respond in writing to an expedited appeal no later than 72 hours after it receives the appeal.37-005.03C2bExpedited Appeal Extension: The PACE organization may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons: 1. The participant requests the extension; or2. The PACE organization justifies to the SAA the need for additional information and how the delay is in the interest of the participant.37-005.03C3Favorable Determination: If a determination is made in favor of the participant on appeal, the PACE organization must furnish the disputed service as expeditiously as the participant's health condition requires.37-005.03C4Adverse Determination: For a determination that is wholly or partially adverse to a participant, the PACE organization must notify the participant, the SAA, and CMS.37-005.03DExternal Appeals: If dissatisfied with the outcome of their internal appeal to the PACE organization, participants may appeal as follows: 37-005.03D1Participants Eligible for Both Medicaid and Medicare: Participants who are eligible for both Medicare and Medicaid have the choice of using either the SAA's or Medicare's appeal process; however, they may only choose one route by which to exercise their external appeal rights. The PACE organization shall assist the participant in choosing which process to pursue if both are applicable, and the PACE organization must forward the appeal to the appropriate external agency.37-005.03D2Participant Eligible Only for Medicare: Participants who are only eligible for Medicare shall appeal through the Independent Review Entity (IRE).37-005.03D3Participants Eligible Only for Medicaid: Participants who are only eligible for Medicaid shall appeal using the SAA's appeal process.37-005.03D4Private Pay Participants: Participants who are private pay shall appeal using the SAA's appeal process.37-005.03EServices Provided During the Appeals Process: During the appeals process, the PACE organization shall continue to provide non-disputed services to a participant. 37-005.03E1Medicaid Recipient: For a participant who is a Medicaid recipient, the PACE organization shall continue to provide the disputed service until the final determination is issued if the following conditions are met: 1. The PACE organization is proposing to terminate or reduce a service currently being furnished to the participant; and2. The participant requests continuation of the provision of services with the understanding that he or she may be liable for the cost of the contested services if the determination is not made in his/her favor.471 Neb. Admin. Code, ch. 37, § 005