DHCS has issued updates and clarifications for Managed Care Plans (MCPs) and Dental Managed Care Plans (DMCs) regarding new federal guidelines around the grievance and appeals process. These rules take effect July 1, 2017. Attachment A summarizes the key changes outlined in the All Plan Letter.
Definitions
The new guidelines clarify some definitions. “Actions” are now called “Adverse Benefit Determinations,” though the definition encompasses all previously existing elements of “Actions.” The guidelines separately define “Grievance” and “Appeal.”
Adverse Benefit Determinations
MCPs must make decisions on requests for services within five business days from receiving reasonably necessary information, but may not exceed 14 calendar days to make a decision. Otherwise, the lack of decision is considered an adverse benefit determination that triggers appeal rights. Expedited requests must be considered within 72 hours. If services are to be terminated, suspended, or reduced, MCPs must notify beneficiaries at least ten days before the action is to take place.
Written notices (NOAs) need to be dated and postmarked within two days of the decision. Starting July 1, DHCS requires MCPs to use a revised NOA template and “Your Rights” attachment. The revised NOA includes information about requesting information relevant to the NOA at no cost. The guidelines lay out what information must be listed in the NOA when the decision is based on medical necessity. Otherwise, NOAs must provide a clear and concise explanation for the decision. These NOAs must be translated into required threshold languages; if the clinical information cannot be translated, the beneficiary must be informed how they can get a verbal translation of the information.
Because of changes to the federal regulations about appeals, DHCS has updated NOA language regarding beneficiary rights to review of adverse decisions. Beneficiaries must request an internal appeal withing 60 calendar days of the date on the NOA. State hearings are an option only after filing an internal grievance. For these reasons, the “Your Rights” attachment for NOAs will primarily inform a beneficiary about internal appeals, while a Notice of Appeal Resolution (NAR) will provide information about filing for a state fair hearing or IMR.
Grievances
The new federal regulations allow beneficiaries, their providers, or authorized representatives to file grievances at any time (as opposed to the current 180 days) either orally or in writing. MCPs must acknowledge grievances in writing within five calendar days of receiving the grievance. MCPs have 30 calendar days to resolve the grievance. Expedited grievances must be considered within 72 hours, so MCPs must timestamp these requests.
Appeals and State Hearings
Under the new regulations, beneficiaries or their authorized representatives will have to file appeals orally or in writing with MCPs within 60 calendar days from the date of the NOA (as opposed to the current 90 days). Oral appeals must be followed with a signed, written copy of the appeal; MCPs must assist beneficiaries in preparing a written appeal. MCPs must acknowledge receipt of an appeal within five calendar days, and they must resolve the appeal within 30 days. Expedited appeals must be resolved within 72 hours of receipt.
When an appeal is not completely in favor of the beneficiary, MCPs must send a NAR with the rationale (clinical information for medical necessity denials, contract provisions for non-covered benefits). The NAR must include a “Your Rights” attachment outlining rights to request a state hearing within 120 calendar days, to receive aid paid pending, and to request an IMR (for Knox-Keene licensed plans). When an appeal is favorable, MCPs must send written notification and authorize the services no later than 72 hours from resolution.
Beneficiaries can request a state fair hearing within 120 days of exhausting an MCP’s internal appeal process and receiving a NAR. The State must reach its decision within 90 days of the date of the request, and within three working days for an expedited request. MCPs would have 72 hours to comply with a hearing decision.
DHCS APL 17-006 (May 9, 2017).
DHCS Dental APL 17-003 (May 24, 2017).