Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-26 - Managed Care Plan › Section 5160-26-08.4 - Managed care: appeal and grievance system

Current through all regulations passed and filed through July 1, 2024
(A) This rule does not apply to MyCare Ohio
			 plans as defined in rule
			 5160-58-01 of the Administrative
			 Code.
(B) Notice of action (NOA) by
			 a managed care organization (MCO) or the single pharmacy benefit manager
			 (SPBM).
(1) When an adverse benefit
			 determination has occurred or will occur, the MCO or SPBM shall provide the
			 affected member with a NOA.
(2) The
			 language and format of the NOA shall comply with the requirements listed in
			 42 CFR
			 438.10 (October 1, 2021), and the NOA shall
			 explain:
(a) The adverse benefit determination
			 the MCO or SPBM 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 MCO or SPBM;
(d) Information
			 related to exhausting the MCO or SPBM appeal process;
(e) The member's right to request a state
			 hearing through the state's hearing system upon exhausting the MCO or SPBM
			 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 these services; and
(i) The date the notice is issued.
(3) NOAs shall be issued within
			 the following time frames:
(a) For a decision
			 to deny or limit authorization of a requested service the MCO or SPBM shall
			 issue a NOA simultaneously with the MCO or SPBM's decision.
(b) For reduction, suspension, or termination
			 of services prior to the member receiving the services previously authorized by
			 the MCO or SPBM, the MCO or SPBM 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 MCO or SPBM 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, 2021), the MCO or SPBM
			 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 MCO or SPBM shall give notice
			 simultaneously with the MCO or SPBM's determination to deny the claim, in whole
			 or part, for a service not covered by medicaid, including a service determined
			 through the MCO or SPBM's prior authorization process as not medically
			 necessary.
(d) For untimely prior
			 authorization, appeal, or grievance resolution, the MCO or SPBM shall give
			 notice simultaneously with the MCO or SPBM becoming aware of the untimely
			 resolution. Service authorization decisions not reached within the time frames
			 specified in rule
			 5160-26-03.1 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.