482 Neb. Admin. Code, ch. 7, § 004

Current through September 17, 2024

Section 482-7-004 - APPEALS PROCESS

The Heritage Health plan or Dental Benefits Manager must notify the member in writing of the appeals process for challenging any adverse benefit determinations. The member, or the provider on behalf of the member, may request an appeal with the Heritage Health plan or Dental Benefits Manager, request a State fair hearing, or both.

004.01.AVENUES FOR REQUESTING AN APPEAL. The member, or the provider with the member's written consent on behalf of the member, has the following avenues for requesting an appeal:

(A) File a Heritage Health plan or Dental Benefits Manager Level Appeal: The member may contact verbally or in writing the Heritage Health plan or Dental Benefits Manager to request a hearing and following that Heritage Health plan's or Dental Benefits Manager's internal appeal process. The request for appeal must be within sixty (60) days from the date on the notice of adverse benefit determination. An appeal filed orally must be followed by a written, signed appeal; or

(B) Request a State Fair Hearing: A member may request a State fair hearing only after the member has exhausted the Heritage Health plans or Dental Benefits Manager's internal appeal process. The member must submit in writing to the DHHS Legal and Regulatory Services within one hundred twenty (120) days from the date of the Heritage Health plan's or Dental Benefits Manager's notice of resolution. Hearings are scheduled and conducted according to the procedures outlined in 465 NAC.

004.02NOTICE OF ADVERSE BENEFIT DETERMINATION. The Heritage Health plan or Dental Benefits Manager must notify the requesting provider, and give the member written notice of any adverse benefit determination. The notice must be in writing and be a language and format that is easily understandable to the member. The notice to the provider need not be in writing.

004.02(A)TIMEFRAMES FOR NOTICE OF ADVERSE BENEFIT DETERMINATION. The following are timeframes for notice of adverse benefit determination:

(i) Denial of Payment: The Heritage Health plan or Dental Benefits Manager must give notice on the date of adverse benefit determination when the adverse benefit determination is a denial of payment.

(ii) Standard Service Authorization Denial: Notice must be given as expeditiously as the member's health condition requires not to exceed fourteen (14) calendar days following the receipt of the request for service. The timeframe may be extended up to fourteen (14) additional calendar days if the member or provider requests the extension or if the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and demonstrates that the delay is in the member's interest. If the timeframe is extended, the member must be provided written notice of the reason for the decision to extend the timeframe and right to file a grievance if he or she disagrees with that decision. The determination must be issued and carried out as expeditiously as the member health condition requires and no later than the date the extension expires.

(iii) Termination, Suspension, or Reduction of Services: Notice must be given at least ten (10) days before the date of adverse benefit determination when the adverse benefit determination is a termination, suspension, or reduction of a previously authorized Medicaid-covered service. The period of advance notice is shortened to five (5) days if probable fraud has been verified. Notice by the date of the adverse benefit determination must be given by the date of the adverse benefit determination for the following circumstances:

(1) Death of the member;

(2) A signed written member statement requesting service termination or giving information requiring termination or reduction of services (where the member understands that this adverse benefit determination must be the result of supplying that information);

(3) The member's admission to an institution where the member is ineligible for further services;

(4) The member's address is unknown and mail directed to him or her has no forwarding address;

(5) The member has been accepted for Medicaid services by another jurisdiction;

(6) The member's physician or dentist prescribes the change in the level of medical care; or

(7) The safety or health of individuals in the facility would be endangered, the resident's health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required by the resident's urgent medical needs.

(iv) Expedited Service Authorization Denial: For cases in which a provider indicates or the Heritage Health plan or Dental Benefits Manager determines that following the standard timeframe could seriously jeopardize the member's life, or health, or ability to attain, maintain, or regain maximum function, an expedited authorization decision must be made and notice provided as expeditiously as the member's health condition requires and no later than seventy-two (72) hours after receipt of the request for service. This timeframe may be extended up to fourteen (14) additional calendar days if the member requests the extension or if the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and demonstrates that the delay is in the member's interest. If the timeframe is extended, the member must be provided written notice of the reason for the decision to extend the timeframe and right to file a grievance if they disagree with that decision. The determination must be issued and carried out as expeditiously as the member's health condition requires and no later than the date the extension expires.

(v) Untimely Service Authorization Decision: Notice must be provided on the date that the timeframes expire when service authorization decisions are not reached within the timeframes for either standard or expedited service authorizations. Untimely service authorizations constitute a denial and are thus adverse benefit determinations.

004.03RESOLUTION AND NOTIFICATION. The Heritage Health plan or Dental Benefits Manager must resolve each appeal, and provide notice, as expeditiously as the member's health condition requires, not to exceed thirty (30) days from the day the appeal is received. This timeframe may be extended up to fourteen (14) calendar days if the member requests an extension or the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and how the delay is in the member's interest. For any extension not requested by the member, notice of the reason for delay must be provided to the member.

004.03(A)WRITTEN NOTICE OF RESOLUTION. Written notice of resolution of the appeal must be provided to the member. The written resolution must include:

(i) Results and date of the appeal resolution; and

(ii) For decisions not wholly in the member's favor:

(1) The right to request a state fair hearing for decisions not wholly in the member's favor;

(2) How to request a State fair hearing;

(3) The right to receive benefits pending a hearing;

(4) How to request the continuation of benefits; and

(5) If the appeal decision is upheld, that the member may be liable for the cost of continued benefits received while the appeal was pending.

004.04CONTINUATION OF BENEFITS. The member may have his or her benefits continue while an appeal is pending.

004.04(A)REQUIREMENTS FOR CONTINUATION OF BENEFITS. The Heritage Health plan or Dental Benefits Manager must continue member benefits if all of the following apply:

(i) The appeal is filed timely, meaning on or before the later of the following:

(1) Ten (10) calendar days of the Heritage Health plan or Dental Benefits Manager mailing of the notice of adverse benefit determination; or

(2) The intended effective date of the proposed adverse benefit determination;

(ii) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;

(iii) The services were ordered by an authorized provider;

(iv) The authorization period has not expired; and

(v) The member requests a continuation of benefits.

004.04(B)REQUIREMENTS FOR ENDING CONTINUED BENEFITS. If the member's benefits are continued or reinstated while the appeal is pending, the benefits must be continued until one of the following occurs:

(i) The member withdraws the appeal;

(ii) The member does not request a fair hearing and continuation of benefits within ten (10) calendar days from when the Heritage Health plan or Dental Benefits Manager mails the notice of adverse resolution to the member's appeal;

(iii) A state fair hearing decision adverse to the member is made; or

(iv) The authorization expires or authorization service limits are met.

004.04(C)RECOVERY OF COSTS DURING CONTINUATION OF BENEFITS. The Heritage Health plan or Dental Benefits Manager may recover the cost of the continuation of benefits furnished to the member while the appeal was pending if the final resolution of the appeal upholds the Heritage Health plan's or Dental Benefits Manager's adverse benefit determination.

004.04(D)PAYMENT OF COSTS DURING CONTINUATION OF BENEFITS. The Heritage Health plan or Dental Benefits Manager must pay for disputed services if the Heritage Health plan or Dental Benefits Manager or State fair hearing decision reverses a decision to deny authorization of services and the member received the disputed services while the appeal was pending.

004.05EXPEDITED APPEALS PROCESS. The Heritage Health plan or Dental Benefits Manager must conduct an expedited review process when the Heritage Health plan or Dental Benefits Manager determines, for a request from the member, or the provider indicates that taking the time for a standard resolution could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function. Expedited appeals must follow all standard appeal regulations. The Heritage Health plan or Dental Benefits Manager must not take punitive action against a provider who either requests an expedited appeal or supports a member's appeal.

004.05(A)REQUESTING AN EXPEDITED APPEAL. The member or provider may file an expedited appeal either orally or in writing. No additional member follow-up is required.

004.05(B)TIMEFRAMES FOR EXPEDITED APPEALS. The Heritage Health plan or Dental Benefits Manager must resolve each expedited appeal and provide notice as expeditiously as the member's health condition requires and in no event longer than seventy-two (72) hours after the Heritage Health plan or Dental Benefits Manager received the appeal. This timeframe may be extended by up to fourteen (14) calendar days if the member requests the extension or if the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and demonstrates that the delay is in the member's interest. For any extension not requested by the member, written notice of the reason for delay must be provided to the member.

004.05(C)TIMEFRAMES FOR PROVIDING EVIDENCE AND ALLEGATIONS. The Heritage Health plan or Dental Benefits Manager must inform the member of the limited time available for the member to present evidence and allegations of fact or law, in person and in writing.

004.05(D)DENIAL OF AN EXPEDITED APPEAL. If the Heritage Health plan or Dental Benefits Manager denies a request for an expedited resolution of an appeal, the Heritage Health plan or Dental Benefits Manager must:

(i) Transfer the appeal to the standard timeframe of no longer than thirty (30) days from the day the Heritage Health plan or Dental Benefits Manager receives the appeal; and

(ii) Make reasonable effort to give the member prompt oral notice of the denial and a written notice within two (2) calendar days.

004.05(E)NOTIFICATION OF APPEAL RESOLUTION. The Heritage Health plan or Dental Benefits Manager must provide written notice of the appeal resolution. In addition to written notice, reasonable effort must be made to provide oral notice of resolution.

482 Neb. Admin. Code, ch. 7, § 004