Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-420 - Member grievances and appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCOs shall comply with (i) the
				  Grievance and Appeal System as identified in 42 CFR 438 Subpart F, (ii) the
				  Enrollee Rights and Protections requirements in 42 CFR 438 Subpart C, (iii) the
				  Medallion contract between DMAS and the MCO, and (iv) any other applicable
				  state or federal statutory or regulatory requirements.
B. MCOs shall at (i) the initiation of new
				  member enrollment, (ii) the initiation of new provider or subcontractor
				  contracts, or (iii) the request of the member, provide to every member the
				  information described in
				  42 CFR
				  438.10(g) concerning
				  grievance and appeal rights and procedures.
C. Disputes between the MCO and the member
				  concerning any aspect of service delivery, including medical necessity and
				  specialist referral, shall be resolved through a verbal or written grievance or
				  appeals process operated by the MCO or through the DMAS appeals process. A
				  provider or other representative who has the member's written consent may act
				  on behalf of a member in the MCO grievance or appeals or the DMAS appeals
				  process.
1. The member, provider, or
				  representative acting on behalf of the member with the member's written consent
				  may file an oral or written grievance or internal appeal with the MCO. The MCO
				  must accept grievances filed at any time. Internal appeal requests must be
				  submitted within 60 days from the date of the notice of adverse benefit
				  determination. Oral requests for internal appeals must be followed up in
				  writing by the member, provider, or the representative acting on behalf of the
				  member with the member's consent, unless the request is for an expedited
				  internal appeal.
2. The member must
				  exhaust the MCO's internal appeals process before appealing to the DMAS Appeals
				  Division. The member may also file a written request for a standard or
				  expedited internal appeal of the MCO's adverse benefit determination with the
				  DMAS Appeals Division within 120 days of the member's receipt of the MCO's
				  internal appeal decision, in accordance with 42 CFR 431 Subpart E; 42 CFR Part
				  438 Subpart F; and
				  12VAC30-110-10
				  through
				  12VAC30-110-370.
3. As specified in
				  12VAC30-110-100,
				  pending the resolution of a grievance, internal appeal, or appeal filed by a
				  member or his representative (including a provider acting on behalf of the
				  member) prior to the effective date of the adverse benefit determination,
				  coverage shall not be terminated or reduced for the member for any reason that
				  is the subject of the grievance or appeal.
4. The MCO shall ensure that neither the
				  individuals nor agents, nor a subordinate of any such individual, who makes
				  decisions on grievances and internal appeals were involved in any previous
				  level of review or decision making. Additionally, where the reason for the
				  grievance or internal appeal involves clinical issues or relates to a denial of
				  a request for an expedited appeal, or where the appeal is based on a lack of
				  medical necessity, the MCO shall ensure that the decision makers are health
				  care professionals with the appropriate clinical expertise in treating the
				  member's condition or disease.
5.
				  The MCO shall provide the member and any representative a reasonable
				  opportunity in person and in writing to present evidence and testimony and to
				  make legal and factual arguments in accordance with
				  42 CFR
				  438.406(b)(4). The MCO shall
				  inform the member of the limited time available for this sufficiently in
				  advance of the resolution timeframe for appeals in accordance with
				  42 CFR
				  438.406(b)(4).
6. The MCO shall provide the member and any
				  representative the member's case file, including medical records, and any new
				  or additional evidence considered, relied upon, or generated by the MCO in
				  connection with the appeal of the adverse benefit determination. This
				  information must be provided free of charge and sufficiently in advance of the
				  resolution timeframe for appeals in accordance with
				  42 CFR
				  438.406(b)(5).