Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-430 - Provider grievances, reconsiderations, and appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCOs shall comply with the
				  requirements of the Administrative Process Act (§§
										2.2-4000 et
				  seq. of the Code of Virginia), the provider appeals regulations at
				  12VAC30-20-500
				  through
				  12VAC30-20-560,
				  the Medallion contract between DMAS and the MCO, and any other applicable state
				  or federal statutory or regulatory requirements.
B. The MCOs shall have a grievance system
				  established to respond to grievances made by network providers. Network
				  provider grievances are not appealable to the DMAS Appeals Division.
C. MCOs shall, at the initiation of new
				  network provider contracts, provide to every network provider the information
				  described in this section concerning grievance, reconsideration, and appeal
				  rights and procedures.
D. Disputes
				  between the MCO and the network provider concerning any aspect of reimbursement
				  shall be resolved through a verbal or written grievance or reconsideration
				  process operated by the MCO or through the DMAS appeals process. A network
				  provider or representative that is authorized by the network provider may act
				  on behalf of a network provider in the MCO grievance or reconsideration or the
				  DMAS appeals process.
E. Disputes
				  arising solely from the MCO's denial or termination of a provider's enrollment
				  in the MCO's network are not appealable to the DMAS Appeals Division.
F. If a network provider has rendered
				  services to a member and has been denied authorization or reimbursement for the
				  services or has received reduced authorization or reimbursement, that provider
				  may request a reconsideration of the denied or reduced authorization or
				  reimbursement. Before appealing to DMAS, network providers must first exhaust
				  all MCO reconsideration processes. The MCO's final denial letter must include a
				  statement that the provider has exhausted its reconsideration rights with the
				  MCO and that the next level of appeal is with DMAS. The final denial letter
				  must include the appeal rights to DMAS in accordance with the provider appeals
				  regulations at
				  12VAC30-20-500
				  through
				  12VAC30-20-560.
G. All network provider appeals to DMAS must
				  be submitted to the DMAS Appeals Division in writing and within 30 days of the
				  MCO's last date of denial.
H. The
				  MCO shall provide information necessary for any DMAS appeal within timeframes
				  established by DMAS.
I. The MCO
				  shall comply with the DMAS appeal decision. A DMAS appeal decision is not
				  appealable by the MCO.
J. The MCO
				  shall maintain a recordkeeping, reporting, and tracking system for complaints,
				  grievances, and reconsiderations that complies with the Medallion contract
				  between DMAS and the MCO. The system shall include a copy of the original
				  complaint, grievance, or reconsideration; the decision; the nature of the
				  decision; and data on the number of reconsiderations filed, the average time to
				  resolve reconsiderations, and the total number of reconsiderations open as of
				  the reporting date.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.