Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-730 - Appeal procedures

Current through Register Vol. 40, No. 24, July 15, 2024
A. At a
				  minimum, the MCO internal appeal shall be conducted pursuant to written
				  procedures as defined in §
										32.1-137.6 of
				  the Code of Virginia and
				  42 CFR
				  438.400 et seq. Such procedures shall be
				  subject to review and approval by DMAS.
B. Any adverse benefit determination upheld
				  in whole or in part by the internal appeal decision issued by the MCO may be
				  appealed by the enrollee to DMAS in accordance with the DMAS client appeals
				  regulations at
				  12VAC30-110-10
				  through
				  12VAC30-110-370.
				  DMAS shall conduct an evidentiary hearing in accordance with
				  12VAC30-110-10
				  through
				  12VAC30-110-370
				  and shall not base any appealed decision on the record established by any
				  internal appeal decision of the MCO. The MCO shall comply with the DMAS appeal
				  decision. The DMAS decision in these matters shall be final and shall not be
				  subject to appeal by the MCO.
C.
				  Appeals of adverse actions by the LDSS, CPU, or DMAS shall be conducted
				  pursuant to 12VAC30-110.
D. Copies
				  of the procedures shall be promptly provided by the MCO or DMAS to applicants
				  and enrollees upon receipt of timely requests for internal appeals or state
				  fair hearings. Such written procedures shall include the following:
1. The right to representation by an attorney
				  or other agent of the applicant's or enrollee's choice, but at no time shall
				  the MCO, LDSS, DSS, or DMAS be required to obtain or compensate attorneys or
				  other agents acting on behalf of applicants or enrollees;
2. The right to timely review of files and
				  other applicable information relevant to the internal appeal or state fair
				  hearing of the decision;
3. The
				  right to fully participate in the internal appeal or state fair hearing
				  process, whether the internal appeal or state fair hearing is conducted in
				  person or in writing, including the presentation of supplemental information
				  during the internal appeal or state fair hearing process;
4. The right to have personal and medical
				  information and records maintained as confidential;
5. The right to a written final decision:
a. For internal appeals to the MCO, within 30
				  calendar days of receipt of the request for an internal appeal; or
b. For state fair hearings, within the time
				  limitations for appeals imposed by federal regulations and as permitted in
				  12VAC30-110-30;
6. For eligibility and enrollment matters, if
				  the applicant's or enrollee's physician or health plan determines that the
				  90-calendar-day timeframe could seriously jeopardize the applicant's or
				  enrollee's life or health or ability to attain, maintain, or regain maximum
				  function, an applicant or enrollee will have the opportunity to request an
				  expedited appeal. Under these conditions, a request for an expedited appeal
				  shall result in a written final decision within 72 hours after DMAS receives
				  the expedited appeal request from the physician or health plan with the case
				  record and information indicating that taking the time for a standard
				  resolution of the appeal request could seriously jeopardize the applicant's or
				  enrollee's life or health or ability to attain, maintain, or regain maximum
				  function, unless the applicant or enrollee requests an extension;
7. For health services matters for FAMIS MOMS
				  enrollees receiving services through an MCO:
a. If the enrollee's physician or health plan
				  determines that the 30-calendar-day timeframe for a standard internal appeal
				  could seriously jeopardize the enrollee's life, health, or ability to attain,
				  maintain, or regain maximum function, an enrollee will have the opportunity to
				  request an expedited internal appeal. Under these conditions, a request for an
				  internal appeal shall result in a written decision by the MCO within 72 hours
				  from the time the expedited internal appeal is requested, unless the applicant,
				  enrollee, or authorized representative requests a delay. If a delay is
				  requested by the applicant, enrollee, or authorized representative, then
				  expedited internal appeal may be extended up to 14 calendar days.
b. If the adverse benefit determination is
				  upheld in whole or in part by the expedited internal appeal decision issued by
				  the MCO, and if the enrollee's physician or health plan determines that the
				  timeframe for a standard appeal to DMAS could seriously jeopardize the
				  enrollee's life or health or ability to attain, maintain, or regain maximum
				  function, an enrollee will have the opportunity to request an expedited appeal
				  to DMAS. Under these conditions, a request for a state fair hearing shall
				  result in a written decision within 72 hours from the time an enrollee requests
				  the expedited appeal, unless the applicant, enrollee, or authorized
				  representative requests or causes a delay. If a delay is requested by the
				  applicant, enrollee, or authorized representative, then the expedited appeal
				  may be extended up to 14 calendar days; and
8. For health services matters for FAMIS MOMS
				  enrollees receiving services through fee-for-service, if the enrollee's
				  physician or health plan determines that the 90-calendar-day timeframe for a
				  standard appeal could seriously jeopardize the enrollee's life, health, or
				  ability to attain, maintain, or regain maximum function, an enrollee will have
				  the opportunity to request an expedited review. Under these conditions, a
				  request for an expedited appeal shall result in a written decision within 72
				  hours from the time the expedited appeal is requested, unless the applicant,
				  enrollee, or authorized representative requests or causes a delay. If a delay
				  is requested or caused by the applicant, enrollee, or authorized
				  representative, then expedited appeal may be extended up to 14 calendar
				  days.