Missouri Code of State Regulations › Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN › Division 10 - Health Care Plan › Chapter 3 - Public Entity Membership › Section 22 CSR 10-3.075 - Review and Appeals Procedure

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates the telephone number
				  for Anthem expedited appeals and the mailing address and website for external
				  review requests.
(1) Claims
				Submissions and Initial Benefit Determinations.
(A) Members shall use the claims and
				administration procedures established by the vendor administering the
				particular service for which coverage, authorization, or payment is
				sought.
(B) Medical and pharmacy
				service claims are divided into three (3) types: pre-service, post-service, and
				concurrent claims.
1. Pre-service claims are
				requests for approval that the plan or vendor requires a member to obtain
				before getting medical care or filling a prescription, such as prior
				authorization or a decision whether a treatment, procedure, or medication is
				medically necessary.
A. Pre-service claims
				must be decided within a reasonable period of time appropriate to the medical
				circumstances, but no later than twenty (20) business days from the date the
				vendor receives the claim. The vendor may extend the time period up to an
				additional thirty (30) days if, for reasons beyond the vendor's control, the
				decision cannot be made within the first twenty (20) days. The vendor must
				notify the member prior to the expiration of the first twenty-(20-) day period,
				explain the reason for the delay, and request any additional information. If
				more information is requested, the member has at least forty-five (45) days to
				provide the information to the vendor. The vendor then must decide the claim no
				later than thirty (30) days after the additional information is supplied or
				after the period of time allowed to supply it ends, whichever is
				first.
B. Urgent care claims are a
				special type of pre-service claim that require a quicker decision because
				waiting the standard time could seriously jeopardize the member's life, health,
				or ability to regain maximum function. A request for an urgent care claim may
				be submitted verbally or in writing and will be decided within seventy-two (72)
				hours. Written confirmation of the decision will be sent by the vendor within
				three (3) business days.
2. Post-service claims are all other claims
				for services including claims after medical or pharmacy services have been
				provided, such as requests for reimbursement or payment of the costs for the
				services provided.
A. Post-service claims must
				be decided within a reasonable period of time, but not later than twenty (20)
				business days after the vendor receives the claim. If, because of reasons
				beyond the vendor's control, more time is needed to review the claim, the
				vendor may extend the time period up to an additional thirty (30) days. The
				vendor must notify the member prior to the expiration of the first twenty (20-)
				day period, explain the reason for the delay, and request any additional
				information. If more information is requested, the member has at least
				forty-five (45) days to provide the information to the vendor. The vendor then
				must decide the claim no later than thirty (30) days after the additional
				information is supplied or after the period of time allowed to supply it ends,
				whichever is first.
3.
				Concurrent claims are claims related to an ongoing course of previously
				approved treatment. If the plan or vendor has approved an ongoing course of
				treatment to be provided over a period of time or number of treatments, any
				reduction or termination of the course of treatment will be treated as a
				benefit denial. The plan or vendor will notify a member in writing prior to
				reducing or ending a previously approved course of treatment in sufficient time
				to allow the member, or the member's provider, to appeal and obtain a
				determination before the benefit is reduced or terminated.
(C) Claims incurred should be furnished to
				the vendor by the provider or the member as soon as reasonably possible. Claims
				filed more than one (1) year after charges are incurred will not be honored.
				All claims are reviewed and/or investigated by the vendor before they are
				paid.
(D) If a member, a provider,
				or authorized representative on behalf of a member, submits a request for
				coverage or a claim for services that is denied in whole or in part, the member
				will receive an initial denial notice within the timeframes described in this
				rule that will include the following information:
1. The reasons for the denial;
2. Reference to the plan provision,
				regulation, statute, clinical criteria, or guideline on which the denial was
				based, with information as to how the member can obtain a copy of the
				provision, regulation, statute, clinical criteria, or guideline free of
				charge;
3. A description of any
				documentation or information that is necessary for the member to provide if
				documentation or information is missing and an explanation as to why the
				documentation or information is needed, if applicable; and
4. Information as to steps the member can
				take to submit an appeal of the denial.