Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part II - Appeal of Adverse Actions › Section 12VAC30-141-70 - 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 the
				  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, local department of social services, 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 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
				  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 or 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 the
				  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, and 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 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
				  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 a delay. If a delay is
				  requested by the applicant, enrollee, or authorized representative, then
				  expedited appeal may be extended up to 14 calendar days.