Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.23 - Grievances And Appeals Of Medicaid Enrollees In Regional Care Organizations And Alternate Care Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 This rule is promulgated pursuant to Section
			 22-6-153(d) of
			 the Code of Ala. 1975, to establish a grievance and appeal system consisting of
			 a grievance process, appeal process, and access to the Medicaid Agency's fair
			 hearing system (the "grievance system") for enrollees in a regional care
			 organization or an alternate care organization (hereafter collectively referred
			 to in this rule as "organization").
(2) For the purposes of this rule an
			 "enrollee" in an organization shall be construed to mean a Medicaid beneficiary
			 currently enrolled in an organization, or a provider authorized in writing on a
			 Medicaid Agency approved form to act on behalf of an enrollee, and any other
			 person authorized in writing on a Medicaid Agency approved form or by court
			 order to act as a representative on behalf of an enrollee who has filed a
			 grievance or appeal pursuant to this rule (all of whom shall be collectively
			 referred to in this rule as "enrollee").
(3) For the purposes of this rule a
			 "grievance" means an expression of dissatisfaction by an enrollee about any
			 matter related to the enrollee's care and treatment by the organization in
			 accordance with
			 42 CFR
			 438.400. A grievance does not include matters
			 that constitute an "action" under the following subsection 5 or any matter that
			 may be in litigation.
(4) An
			 enrollee may submit a grievance orally or in writing to the organization within
			 5 business days of learning of the basis of the grievance. A grievance may only
			 be filed with the organization. The organization must acknowledge receipt of
			 the grievance within 5 business days, consider each enrollee grievance and,
			 provide notice of the resolution of the grievance as expeditiously as the
			 enrollee's health condition requires and in any event no more than 30 calendar
			 days from receipt of the grievance. The organization must assign a person(s)
			 not directly involved in the matter that is the subject of the grievance to
			 conduct a reasonable review of the circumstances surrounding the grievance. The
			 reviewer shall review any relevant parts of the enrollee's case file and
			 medical records as well as all documents submitted on behalf of the enrollee
			 and may, as it deems necessary, conduct additional investigation into the
			 grievance and/or consult with medical or behavioral professionals. The response
			 to the grievance by the organization shall be in writing and fully explain the
			 decision reached as to each part of the grievance presented and the reasons for
			 the decision. Enrollees have no right to appeal an adverse determination of a
			 grievance. The failure on the part of an organization to act on a grievance as
			 required by this section shall constitute an action under subsection
			 5.
(5) For the purposes of this
			 rule an "action" means action the organization has taken or plans to take that
			 could result in a material change or limitation to enrollee's care and
			 treatment including but not limited to the approval or denial of care, adverse
			 decisions related to billing and payment or bundling matters, and other
			 decisions related to the provision of health care services offered, made
			 available or denied to the enrollee by the organization that constitutes an
			 action under
			 42 CFR
			 438.400. For the purposes of this rule "the
			 provision of health care services" shall include, but not be limited to, the
			 denial or limited authorization of a claim or requested service, including the
			 type or level of service; the reduction, suspension, or termination of an
			 authorized service; the total or partial denial of payment for a service; the
			 failure to provide services in a timely manner as required by state or federal
			 law or rules of the Medicaid Agency; the failure of an organization to act
			 within timeframes established by the Medicaid Agency or within the timeframes
			 provided in
			 42 CFR
			 438.408(b); or in applicable
			 cases, the denial of an enrollee's request to exercise his or her right to
			 obtain services outside of the delivery network of the organization. For the
			 purposes of this rule, an appeal shall be construed to mean the request for
			 review of an "action."
(6)
(a) In the event the organization takes or
			 decides to take an action (as defined herein) regarding an enrollee, a written
			 "notice of action" shall be provided to the enrollee as expeditiously as
			 possible but whenever possible not less than 10 calendar days before the date
			 of any proposed action that would involve termination, suspension or reduction
			 of a previously authorized covered service, unless the delay resulting from
			 such a notice is reasonably believed to be injurious to enrollee's health and
			 welfare by enrollee's treating physicians or except as otherwise required by
			 §438.404(c). The notice shall be sent by mail to enrollee's last known
			 address and may also be communicated to enrollee by email or facsimile
			 transmission. All such notices of action must at a minimum, clearly and
			 thoroughly explain, on forms approved by the Medicaid Agency:
1. The action the organization has taken or
			 proposes to take and when;
2. The
			 reasons for the action taken or proposed;
3. The full rights of appeal the enrollee has
			 to challenge the action under the provisions of this rule and Section
			 22-6-153(d),
			 including but not limited to the right to seek an expedited appeal in certain
			 cases;
4. The procedures an
			 enrollee must follow to exercise his/her rights to appeal;
5. The enrollee's right to request and
			 receive a continuation of benefits pending resolution of the appeal, the
			 process to request continuation of benefits and the circumstance under which
			 the enrollee may later be required to pay for the services continued during
			 appeal; and
6. The time by which
			 all appeals must be filed by the enrollee.