Ohio Administrative Code|Rule 5160-26-08.4 | Managed health care programs: managed care plan appeal and grievance system.

                                                
This rule does not apply to MyCare Ohio plans as
		defined in rule 5160-58-01 of the Administrative Code. Provisions regarding
		appeals and grievances for MyCare Ohio are described in Chapter 5160-58 of the
		Administrative Code.
(A) Definitions.
(1) "Adverse benefit
			 determination" is a managed care plan (MCP)'s:
(a) Denial or limited authorization of a requested service,
				including determinations based on the type or level of service, requirements
				for medical necessity, appropriateness, setting, or effectiveness of a covered
				benefit;
(b) Reduction, suspension, or termination of services prior
				to the member receiving the services previously authorized by the
				MCP;
(c) Denial, in whole or part, of payment for a
				service;
(d) Failure to provide services in a timely manner as
				specified in rule 5160-26-03.1 of the Administrative Code;
(e) Failure to act within the resolution time frames
				specified in this rule; or
(f) Denial of a member's request to dispute a
				financial liability, including cost sharing, copayments, premiums, deductibles,
				coinsurance and other member financial liabilities, if applicable.
(2) "Appeal" is
			 the member's request for an MCP's review of an adverse benefit
			 determination.
(3) "Grievance"
			 is the member's expression of dissatisfaction about any matter other than
			 an adverse benefit determination. Grievances may include, but are not limited
			 to, the quality of care or services provided, and aspects of interpersonal
			 relationships such as rudeness of a provider or employee, or failure to respect
			 the members rights regardless of whether remedial action is requested.
			 Grievance includes a members right to dispute an extension of time
			 proposed by the MCP to make an authorization decision.
(4) "Notice of
			 action (NOA)" is the written notice an MCP must provide to members when an
			 MCP adverse benefit determination has occurred or will occur.
(B) NOA by an MCP.
(1) When an MCP adverse
			 benefit determination has occurred or will occur, the MCP 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, 2017), and the NOA shall explain:
(a) The adverse benefit determination the MCP 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
				MCP;
(d) Information related to exhausting the MCP
				appeal;
(e) The member's right to request a state hearing
				through the state's hearing system upon exhausting the MCP
				appeal;
(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) An MCP shall issue
			 each NOA within the following time frames:
(a) For a decision to deny or limit authorization of a
				requested service the MCP shall issue a NOA simultaneously with the MCP's
				decision.
(b) For reduction, suspension, or termination of services
				prior to the member receiving the services previously authorized by the MCP,
				the MCP 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 MCP 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, 2017), the MCP 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
				MCP shall give notice simultaneously with the MCP's determination to deny
				the claim, in whole or part, for a service not covered by medicaid, including a
				service determined through the MCP's prior authorization process as not
				medically necessary.
(d) For untimely prior authorization, appeal, or grievance
				resolution, the MCP shall give notice simultaneously with the MCP 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.
(C) Grievances to an MCP.
(1) A member may file a
			 grievance with an MCP orally or in writing at any time. An authorized
			 representative must have the member's written consent to file a grievance
			 on the member's behalf.
(2) An MCP shall acknowledge the receipt
			 of each grievance to the member filing the grievance. Oral acknowledgment by an
			 MCP is acceptable. If the grievance is filed in writing, written acknowledgment
			 shall be made within three business days of receipt of the
			 grievance.
(3) An MCP shall review and resolve all
			 grievances as expeditiously as the member's health condition requires.
			 Grievance resolutions, including member notification, shall meet the following
			 time frames:
(a) Within two business days of receipt if the grievance is
				regarding access to services.
(b) Within thirty calendar days of receipt for non
				claims-related grievances except as specified in paragraph (C)(3)(a) of this
				rule.
(c) Within sixty calendar days of receipt for
				claims-related grievances.
(4) At a minimum, an MCP shall provide
			 oral notification to the member of a grievance resolution. If an MCP is unable
			 to speak directly with the member, or the resolution includes information that
			 must be confirmed in writing, the resolution shall be provided in writing
			 simultaneously with the MCP's resolution.
(5) If an MCP's resolution to a
			 grievance is to uphold the denial, reduction, suspension, or termination of a
			 service or billing of a member due to the MCP's denial of payment for that
			 service, the MCP shall notify the member of his or her right to request a state
			 hearing as specified in paragraph (G) of this rule, if the member has not
			 previously been notified.
(D) Standard appeal to an MCP.
(1) A member, a
			 member's authorized representative, or a provider may file an appeal
			 orally or in writing within sixty calendar days from the date that the NOA was
			 issued. An oral appeal filing must be followed with a written appeal. An MCP
			 shall:
(a) Immediately convert an oral appeal filing to a written
				appeal on behalf of the member; and
(b) Consider the date of the oral appeal filing as the
				filing date.
(2) Any provider acting
			 on the member's behalf shall have the member's written consent to
			 file an appeal. An MCP shall begin processing the appeal upon receipt of the
			 written consent.
(3) An MCP shall
			 acknowledge receipt of each appeal to the member filing the appeal. At a
			 minimum, acknowledgment shall be made in the same manner the appeal was filed.
			 If an appeal is filed in writing, written acknowledgment shall be made by an
			 MCP within three business days of receipt of the appeal.
(4) An MCP shall provide
			 the member reasonable opportunity to present evidence and allegations of fact
			 or law, in person as well as in writing, and inform the member of this
			 opportunity sufficiently in advance of the resolution time frame. Upon request,
			 the member and/or member's authorized representative shall be provided,
			 free of charge and sufficiently in advance of the resolution time frame, the
			 case file, including medical records, other documents and records, and any new
			 or additional evidence considered, relied upon or generated by the MCP, or at
			 the direction of the MCP, in connection with the appeal of the adverse benefit
			 determination.
(5) An MCP shall consider
			 the member, the member's authorized representative, or an estate
			 representative of a deceased member as parties to the appeal.
(6) An MCP shall review
			 and resolve each appeal as expeditiously as the member's health condition
			 requires, but the resolution time frame shall not exceed fifteen calendar days
			 from the receipt of the appeal unless the resolution time frame is extended as
			 outlined in paragraph (F) of this rule.
(7) An MCP shall provide
			 written notice of the appeal's resolution to the member, and to the
			 member's authorized representative if applicable. At a minimum, the
			 written notice shall include the resolution decision and date of the
			 resolution.
(8) For appeal
			 resolutions not resolved wholly in the member's favor, the written notice
			 to the member shall also include the following information:
(a) The right to request a state hearing through the
				state's hearing system; 
(b) How to request a state hearing; and if
				applicable:
(i) The right to continue
				  to receive benefits pending a state hearing;
(ii) How to request the
				  continuation of benefits; and
(iii) If the MCP's
				  adverse benefit determination is upheld at the state hearing, the member may be
				  liable for the cost of any continued benefit.
(c) Oral interpretation is available for any
				language;
(d) Written translation is available in prevalent
				non-English languages as applicable;
(e) Written alternative formats may be available as needed;
				and
(f) How to access the MCP's interpretation and
				translation services as well as alternative formats that can be provided by the
				MCP.
(9) For appeal
			 resolutions decided in favor of the member, an MCP shall:
(a) Authorize or provide the disputed services promptly and
				as expeditiously as the member's health condition requires, but no later
				than seventy-two hours from the appeal resolution date, if the services were
				not furnished while the appeal was pending.
(b) Pay for the disputed services if the member received
				the services while the appeal was pending.
(E) Expedited appeals to an MCP.
(1) An MCP shall
			 establish and maintain an expedited review process to resolve appeals when the
			 member requests and the MCP determines, or the provider indicates in making the
			 request on the member's behalf or supporting the member's request,
			 that the standard resolution time frame could seriously jeopardize the
			 member's life, physical or mental health or ability to attain, maintain,
			 or regain maximum function.
(2) In utilizing an
			 expedited appeal process, an MCP shall comply with the standard appeal process
			 specified in paragraph (D) of this rule, except the MCP shall:
(a) Determine within one business day of the appeal request
				whether to expedite the appeal resolution;
(b) Make reasonable efforts to provide prompt oral
				notification to the member of the decision to expedite or not expedite the
				appeal resolution;
(c) Inform the member of the limited time available for the
				member to present evidence and allegations of fact or law in person or in
				writing;
(d) Resolve the appeal as expeditiously as the
				member's health condition requires, but the resolution time frame shall
				not exceed seventy-two hours from the date the MCP received the appeal unless
				the resolution time frame is extended as outlined in paragraph (F) of this
				rule;
(e) Make reasonable efforts to provide oral notice of the
				appeal resolution in addition to the required written
				notification;
(f) Ensure punitive action is not taken against a provider
				who requests an expedited resolution or supports a member's appeal;
				and
(g) Notify ODM within one business day of any appeal that
				meets the criteria for expedited resolution as specified by ODM.
(3) If an MCP denies a
			 member's request for expedited resolution of an appeal, the MCP
			 shall:
(a) Transfer the appeal to the standard resolution time
				frame of fifteen calendar days from the date the appeal was received unless the
				resolution time frame is extended as outlined in paragraph (F) of this
				rule;
(b) Make reasonable efforts to provide the member prompt
				oral notification of the decision not to expedite, and within two calendar days
				of the receipt of the appeal, provide the member written notice of the reason
				for the denial, including information that the member can grieve the
				decision.
(F) Grievance and appeal resolution
		  extensions.
(1) A member may request
			 the time frame for an MCP to resolve a grievance or a standard or expedited
			 appeal be extended up to fourteen calendar days.
(2) An MCP may request
			 the time frame to resolve a grievance or a standard or expedited appeal be
			 extended up to fourteen calendar days. The following requirements
			 apply:
(a) The MCP shall seek such an extension from ODM prior to
				the expiration of the standard or expedited appeal or grievance resolution time
				frame;
(b) The MCP request shall be supported by documentation of
				the need for additional information and that the extension is in the
				member's best interest; and
(c) If ODM approves the extension, the MCP shall make
				reasonable efforts to provide the member prompt oral notification of the
				extension and, within two calendar days, provide the member written notice of
				the reason for the extension and the date by which a decision shall be
				made.
(3) An MCP shall maintain
			 documentation of any extension request.
(G) Access to state's hearing system.
(1) Except as set forth in paragraph
			 (G)(2) of this rule, and in accordance with 42 CFR 438.402 (October 1, 2017),
			 members may request a state hearing only after exhausting the MCP's appeal
			 process. If an MCP fails to adhere to the notice and timing requirements for
			 appeals set forth in this rule, the member is deemed to have exhausted the MCP
			 appeal process and may request a state hearing.
(2) In accordance with rule 5160-20-01 of
			 the Administrative Code, members proposed for enrollment or currently enrolled
			 in the coordinated services program (CSP) are afforded state hearing rights in
			 accordance with division 5101:6 of the Administrative Code and are not subject
			 to the requirement of first appealing to the MCP.
(3) When required by
			 paragraph (D)(8) of this rule, and in accordance with division 5101:6 of the
			 Administrative Code, an MCP shall notify members, and any authorized
			 representatives on file with the MCP, of the right to a state hearing subject
			 to the following requirements:
(a) If an MCP appeal resolution upholds the denial of a
				request for the authorization of a service, in whole or in part, the MCP shall
				simultaneously issue the "Notice of Denial of Medical Services By Your
				Managed Care Plan" (ODM 04043, 1/2018).
(b) If an MCP appeal resolution upholds the decision to
				reduce, suspend, or terminate services prior to the member receiving the
				services as previously authorized by the MCP, the MCP shall issue the
				"Notice of Reduction, Suspension or Termination of Medical Services By
				Your Managed Care Plan" (ODM 04066, 1/2018).
(c) If an MCP learns a member has been billed for services
				received by the member due to the MCP's denial of payment, and the MCP
				upholds the denial of payment, the MCP shall immediately issue the "Notice
				of Denial of Payment for Medical Services By Your Managed Care Plan" (ODM
				04046, 1/2018).
(4) The member or
			 member's authorized representative may request a state hearing within one
			 hundred twenty days from the date of an adverse appeal resolution by contacting
			 the ODJFS bureau of state hearings or local county department of job and family
			 services (CDJFS).
(5) There are no state
			 hearing rights for a member terminated from an MCP pursuant to an MCP-initiated
			 membership termination as permitted in rule 5160-26-02.1 of the Administrative
			 Code.
(6) Following the bureau
			 of state hearing's notification to an MCP that a member has requested a
			 state hearing, the MCP shall:
(a) Complete the "Appeal Summary for Managed Care
				Plans" (ODM 01959, 7/2014) with appropriate supporting attachments, and
				file it with the bureau of state hearings at least three business days prior to
				the scheduled hearing date. The appeal summary shall include all facts and
				documents relevant to the issue, in accordance with rule 5160-26-03.1 of the
				Administrative Code, and be sufficient to demonstrate the basis for the
				MCP's adverse benefit determination;
(b) Send a copy of the completed ODM 01959 to the member
				and the member's authorized representative, if applicable, the CDJFS, and
				the designated ODM contact; and
(c) If benefits were continued through the appeal process
				in accordance with paragraph (H)(1) of this rule, continue or reinstate the
				benefit(s) if the MCP is notified that the member's state hearing request
				was received within fifteen days from the date of the appeal
				resolution.
(7) An MCP shall
			 participate in the state hearing, in person or by telephone, on the date
			 indicated on the "Notice to Appear for a Scheduled Hearing" (JFS
			 04002, 01/2015) sent to the MCP by the bureau of state hearings.
(8) An MCP shall comply
			 with the state hearing decision provided to the MCP via the "State Hearing
			 Decision" (JFS 04005, 01/2015). If the state hearing decision sustains the
			 member's appeal, the MCP shall submit the information required by the
			 "Order of Compliance" (JFS 04068, 01/2015) to the bureau of state
			 hearings. The information, including applicable supporting documentation, is
			 due to the bureau of state hearings and the designated ODM contact by no later
			 than the compliance date specified in the hearing decision. If applicable, the
			 MCP shall:
(a) Authorize or provide the disputed services promptly and
				as expeditiously as the member's health condition requires, but no later
				than seventy-two hours from the date it receives notice reversing the adverse
				benefit determination if services were not furnished while the appeal was
				pending.
(b) Pay for the disputed services if the member received
				the services while the appeal was pending.
(H) Continuation of benefits while the appeal to an MCP or
		  state hearing are pending.
(1) Unless a member
			 requests that previously authorized benefits not be continued, an MCP shall
			 continue a member's benefits when all the following conditions are
			 met:
(a) The member requests an appeal within fifteen days of
				the MCP issuing the NOA;
(b) The appeal involves the termination, suspension, or
				reduction of services prior to the member receiving the previously authorized
				services;
(c) The services were ordered by an authorized provider;
				and
(d) The authorization period has not expired.
(2) If an MCP continues
			 or reinstates the member's benefits while the appeal or state hearing are
			 pending, the benefits shall be continued until one of the following
			 occurs:
(a) The member withdraws the appeal or the state hearing
				request;
(b) The member fails to request a state hearing within
				fifteen days after the MCP issues an adverse appeal resolution; or
(c) The bureau of state hearings issues a state hearing
				decision upholding the reduction, suspension or termination of
				services.
(3) If the final
			 resolution of the appeal or state hearing upholds an MCP's original
			 adverse benefit determination, at the discretion of ODM, the MCP may recover
			 the cost of the services furnished to the member while the appeal and/or state
			 hearing was pending.
(I) Other duties of an MCP regarding appeals and
		  grievances.
(1) An MCP shall give
			 members all reasonable assistance filing a grievance, an appeal, or a state
			 hearing request including but not limited to:
(a) Explaining the MCP's process to be followed in
				resolving the member's appeal or grievance;
(b) Completing forms and taking other procedural steps as
				outlined in this rule; and
(c) Providing oral interpretation and oral translation
				services, sign language assistance, and access to the appeals and grievance
				system through a toll-free number with text telephone yoke (TTY) and
				interpreter capability.
(2) An MCP shall ensure
			 the individuals who make decisions on appeals and grievances are individuals
			 who:
(a) Were neither involved in any previous level of review
				or decision-making nor a subordinate of any such individual; and
(b) Are health care professionals who have the appropriate
				clinical expertise in treating the member's condition or disease if
				deciding any of the following:
(i) An appeal of a denial
				  based on lack of medical necessity;
(ii) A grievance
				  regarding the denial of an expedited resolution of an appeal; or
(iii) An appeal or
				  grievance involving clinical issues.
(3) In reaching an appeal resolution, an
			 MCP shall take into account all comments, documents, records, and other
			 information submitted by the member or their authorized representative without
			 regard to whether such information was submitted or considered in the initial
			 adverse benefit determination.