Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-58 - MyCare Ohio › Section 5160-58-08.4 - Appeals and grievances for "MyCare Ohio"

Current through all regulations passed and filed through July 1, 2024
(A) Notice of action (NOA) by a MyCare Ohio
			 plan (MCOP).
(1) When an MCOP adverse benefit
			 determination has or will occur, the MCOP shall provide the affected member
			 with a NOA.
(2) The NOA shall
			 explain:
(a) The adverse benefit determination
			 the MCOP has taken or intends to take;
(b) The reasons for the adverse benefit
			 determination, including the right of the member to be provided, upon request
			 and free of charge, reasonable access to copies of all documents, records, and
			 other relevant determination information;
(c) The member's right to file an appeal to
			 the MCOP;
(d) Information related
			 to exhausting the MCOP appeal;
(e)
			 The member's right to request a state hearing through the state's hearing
			 system upon exhausting the MCOP appeal process;
(f) Procedures for exercising the member's
			 rights to appeal the adverse benefit determination;
(g) Circumstances under which expedited
			 resolution is available and how to request it;
(h) If applicable, the member's right to have
			 benefits continue pending the resolution of the appeal, how to request that
			 benefits be continued, and the circumstances under which the member may be
			 required to pay for the cost of those services;
(i) The date the notice is issued;
(3) The following language and
			 format requirements apply to a NOA issued by an MCOP:
(a) It shall be provided in a manner and
			 format that may be easily understood;
(b) It shall explain that oral interpretation
			 is available for any language, written translation is available in prevalent
			 non-English languages as applicable, and written alternative formats may be
			 available as needed;
(c) It shall
			 explain how to access the MCOP's interpretation and translation services as
			 well as alternative formats that can be provided by the MCOP;
(d) When directed by ODM, it shall be printed
			 in the prevalent non-English languages of members in the MCOP's service area;
			 and
(e) It shall be available in
			 alternative formats, and in an appropriate manner, taking into consideration
			 the special needs of members, including but not limited to members who are
			 visually limited and members who have limited reading proficiency.
(4) An MCOP shall issue a NOA
			 within the following time frames:
(a) For a
			 decision to deny or limit authorization of a requested service, the MCOP shall
			 issue a NOA simultaneously with the MCOP's decision.
(b) For reduction, suspension, or termination
			 of services prior to the member receiving the services previously authorized by
			 the MCOP, the MCOP shall give notice at least fifteen calendar days before the
			 effective date of the adverse benefit determination except:
(i) If probable recipient fraud has been
			 verified, the MCOP shall give notice five calendar days before the effective
			 date of the adverse benefit determination.
(ii) Under the circumstances set forth in
			 42 CFR
			 431.213 (October 1, 2022), the MCOP shall
			 give notice on or before the effective date of the adverse benefit
			 determination.
(c) For
			 denial of payment for a non-covered service, the MCOP shall give notice
			 simultaneously with the MCOP's action to deny the claim, in whole or part, for
			 a service that is not covered by medicaid, including a service that was
			 determined through the MCOP's prior authorization process as not medically
			 necessary.
(d)
			 For untimely prior authorization, appeal, or grievance resolution, the MCOP
			 shall give notice simultaneously with the MCOP becoming aware of the untimely
			 resolution. Service authorization decisions not reached within the time frames
			 specified in rules
			 5160-26-03.1 and
			 5160-58-01.1 of the
			 Administrative Code constitutes a denial and is thus considered to be an
			 adverse benefit determination. Notice shall be given on the date the
			 authorization decision time frame expires.