22 CSR 10-3.075 - [Effective 6/29/2025] Review and Appeals Procedure
(1) Claims Submissions and Initial Benefit
Determinations.
(A) Members shall use the
claims and administration procedures established by the vendor administering
the particular service for which coverage, authorization, or payment is
sought.
(B) Medical and pharmacy
service claims are divided into three (3) types: pre-service, post-service, and
concurrent claims.
1. Pre-service claims are
requests for approval that the plan or vendor requires a member to obtain
before getting medical care or filling a prescription, such as prior
authorization or a decision whether a treatment, procedure, or medication is
medically necessary.
A. Pre-service claims
must be decided within a reasonable period of time appropriate to the medical
circumstances, but no later than twenty (20) business days from the date the
vendor receives the claim. The vendor may extend the time period up to an
additional thirty (30) days if, for reasons beyond the vendor's control, the
decision cannot be made within the first twenty (20) days. The vendor must
notify the member prior to the expiration of the first twenty- (20-) day
period, explain the reason for the delay, and request any additional
information. If more information is requested, the member has at least
forty-five (45) days to provide the information to the vendor. The vendor then
must decide the claim no later than thirty (30) days after the additional
information is supplied or after the period of time allowed to supply it ends,
whichever is first.
B. Urgent care
claims are a special type of pre-service claim that require a quicker decision
because waiting the standard time could seriously jeopardize the member's life,
health, or ability to regain maximum function. A request for an urgent care
claim may be submitted verbally or in writing and will be decided within
seventy-two (72) hours. Written confirmation of the decision will be sent by
the vendor within three (3) business days.
2. Post-service claims are all other claims
for services including claims after medical or pharmacy services have been
provided, such as requests for reimbursement or payment of the costs for the
services provided.
A. Post-service claims must
be decided within a reasonable period of time, but not later than twenty (20)
business days after the vendor receives the claim. If, because of reasons
beyond the vendor's control, more time is needed to review the claim, the
vendor may extend the time period up to an additional thirty (30) days. The
vendor must notify the member prior to the expiration of the first twenty-
(20-) day period, explain the reason for the delay, and request any additional
information. If more information is requested, the member has at least
forty-five (45) days to provide the information to the vendor. The vendor then
must decide the claim no later than thirty (30) days after the additional
information is supplied or after the period of time allowed to supply it ends,
whichever is first.
3.
Concurrent claims are claims related to an ongoing course of previously
approved treatment. If the plan or vendor has approved an ongoing course of
treatment to be provided over a period of time or number of treatments, any
reduction or termination of the course of treatment will be treated as a
benefit denial. The plan or vendor will notify a member in writing prior to
reducing or ending a previously approved course of treatment in sufficient time
to allow the member, or the member's provider, to appeal and obtain a
determination before the benefit is reduced or terminated.
(C) Claims incurred should be furnished to
the vendor by the provider or the member as soon as reasonably possible. Claims
filed more than one (1) year after charges are incurred will not be honored.
All claims are reviewed and/or investigated by the vendor before they are
paid.
(D) If a member, a provider,
or authorized representative on behalf of a member, submits a request for
coverage or a claim for services that is denied in whole or in part, the member
will receive an initial denial notice within the time frames described in this
rule that will include the following information:
1. The reasons for the denial;
2. Reference to the plan provision,
regulation, statute, clinical criteria, or guideline on which the denial was
based, with information as to how the member can obtain a copy of the
provision, regulation, statute, clinical criteria, or guideline free of
charge;
3. A description of any
documentation or information that is necessary for the member to provide if
documentation or information is missing and an explanation as to why the
documentation or information is needed, if applicable; and
4. Information as to steps the member can
take to submit an appeal of the denial.
(2) General Appeal Provisions.
(A) All individuals seeking review or appeal
of a decision of the plan, plan administrator, claims administrator, or any
vendor shall follow the procedures applicable to the type of decision appealed
as set forth in this rule.
(B) All
appeals must be submitted in writing to the appropriate reviewer as established
in this rule by the member, the individual seeking review, or his/her
authorized representative.
(C)
Unless specifically provided otherwise in this rule, all appeals to the plan,
plan administrator, claims administrator, or applicable vendor must be made,
initiated in writing, within one hundred eighty (180) days of issuance of the
denial or notice which gave rise to the appeal.
(3) Appeal Process for Medical and Pharmacy
Determinations.
(A) Definitions.
Notwithstanding any other rule in this chapter to the contrary, for purposes of
a member's right to appeal any adverse benefit determination made by the plan,
the plan administrator, a claims administrator, or a medical or pharmacy
benefit vendor, relating to the provision of health care benefits, other than
those provided in connection with the plan's dental or vision benefit offering,
the following definitions apply:
1. Adverse
benefit determination. An adverse benefit determination means any of the
following:
A. A denial, reduction, or
termination of, or a failure to provide or make payment (in whole or in part)
for a benefit, including any denial, reduction, termination, or failure to
provide or make payment that is based on a determination of an individual's
eligibility to participate in the plan;
B. A denial, reduction, or termination of, or
a failure to provide or make payment (in whole or in part) for a benefit
resulting from the application of any utilization review, as well as a failure
to cover an item or service for which benefits are otherwise provided because
it is determined to be experimental or investigational or not medically
necessary or appropriate; or
C. Any
rescission of coverage after an individual has been covered under the
plan;
2. Appeal (or
internal appeal). An appeal or internal appeal means review by the plan, the
plan administrator, a claims administrator, or a medical or pharmacy benefit
vendor of an adverse benefit determination;
3. Claimant. Claimant means an individual who
makes a claim under this subsection. For purposes of this subsection,
references to claimant include a claimant's authorized
representative;
4. External review.
The United States Department of Health and Human Services (HHS) conducts
external reviews for adverse benefit determinations regarding medical and
pharmacy benefits administered by Anthem and Express Scripts, Inc. that involve
medical judgment (including, but not limited to, those based on medical
necessity, appropriateness, health care setting, level of care, or
effectiveness of a covered benefit; or a determination that a treatment is
experimental or investigational) and a rescission of coverage (regardless of
whether or not the rescission has any effect on any particular benefit at that
time);
5. Final internal adverse
benefit determination. A final internal adverse benefit determination means an
adverse benefit determination that has been upheld by the plan, the plan
administrator, a claims administrator, or a medical or pharmacy benefit vendor
at the completion of the internal appeals process under this subsection, or an
adverse benefit determination with respect to which the internal appeals
process has been deemed exhausted by application of applicable state or federal
law;
6. Final external review
decision. A final external review decision means a determination rendered under
the external review process at the conclusion of an external review;
and
7. Rescission. A rescission
means a termination or discontinuance of medical or pharmacy coverage that has
retroactive effect, except that a termination or discontinuance of coverage is
not a rescission if-
A. The termination or
discontinuance of coverage has only a prospective effect; or
B. The termination or discontinuance of
coverage is effective retroactively to the extent it is attributable to a
failure to timely pay required premiums or contributions towards the cost of
coverage.
(B)
Internal Appeals.
1. Eligibility, termination
for failure to pay, or rescission. Adverse benefit determinations denying or
terminating an individual's coverage under the plan based on a determination of
the individual's eligibility to participate in the plan or the failure to pay
premiums or any rescission of coverage based on fraud or intentional
misrepresentation of a member or authorized representative of a member are
appealable exclusively to the Missouri Consolidated Health Care Plan (MCHCP)
Board of Trustees (board).
A. The internal
review process for appeals relating to eligibility, termination for failure to
pay, or rescission shall consist of one (1) level of review by the
board.
B. Adverse benefit
determination appeals to the board must identify the eligibility, termination,
or rescission decision being appealed and the reason the claimant believes the
MCHCP staff decision should be overturned. The member should include with
his/her appeal any information or documentation to support his/her appeal
request.
C. The appeal will be
reviewed by the board in a meeting closed pursuant to section
610.021, RSMo, and the appeal
will be responded to in writing to the claimant within sixty (60) days from the
date the board received the written appeal.
D. Determinations made by the board
constitute final internal adverse benefit determinations and are not eligible
for external review, except as specifically provided in
22 CSR
10-3.075(4)(A) 4.
2. Medical and pharmacy services. Members may
request internal review of any adverse benefit determination relating to urgent
care, pre-service claims, and post-service claims made by the plan's medical
and pharmacy vendors.
A. Appeals of adverse
benefit determinations shall be submitted in writing to the vendor that issued
the original determination giving rise to the appeal at the applicable address
set forth in this rule.
B. The
internal review process for adverse benefit determinations relating to medical
services consists of two (2) levels of internal review provided by the medical
vendor that issued the adverse benefit determination.
(I) First level appeals must identify the
decision being appealed and the reason the member believes the original claim
decision should be overturned. The member should include with his/her appeal
any additional information or documentation to support the reason the original
claim decision should be overturned.
(II) First level appeals will be reviewed by
the vendor by someone who was not involved in the original decision and will
consult with a qualified medical professional if a medical judgment is
involved. First level medical appeals will be decided within twenty (20)
business days from the date the vendor received the first level appeal request.
(a) If, because of reasons beyond the
vendor's control, more time is needed to review the appeal, the vendor may
extend the time period up to an additional thirty (30) days. The vendor must
notify the member prior to the expiration of the first twenty- (20-) day
period, explain the reason for the delay, and request any additional
information. If more information is requested, the member has at least
forty-five (45) days to provide the information to the vendor. The vendor then
must decide the claim no later than thirty (30) days after the additional
information is supplied or after the period of time allowed to supply it ends,
whichever is first. Written confirmation of the decision will be sent by the
vendor within fifteen (15) business days.
(III) An expedited appeal of an adverse
benefit determination may be requested when a decision is related to a
pre-service claim for urgent care. Expedited appeals will be reviewed by the
vendor by someone who was not involved in the original decision and will
consult with a qualified medical professional if a medical judgment is
involved. Expedited appeals will be responded to within seventy-two (72) hours
after receiving a request for an expedited review with written confirmation of
the decision to the member within three (3) business days of providing
notification of the determination.
(IV) Second level appeals must be submitted
in writing within sixty (60) days of the date of the first level appeal
decision letter that upholds the original adverse benefit determination. Second
level appeals should include any additional information or documentation to
support the reason the member believes the first level appeal decision should
be overturned. Second level appeals will be reviewed by the vendor by someone
who was not involved in the original decision or first level appeal and will
include consultation with a qualified medical professional if a medical
judgment is involved. Second level medical appeals will be decided within
twenty (20) days for post-service claims and within fifteen (15) days for
pre-service claims from the date the vendor received the second level appeal
request.
(a) If, because of reasons beyond the
vendor's control, more time is needed to review the appeal, the vendor may
extend the time period up to an additional thirty (30) days. The vendor must
notify the member prior to the expiration of the first twenty- (20-) day
period, explain the reason for the delay, and request any additional
information. If more information is requested, the member has at least
forty-five (45) days to provide the information to the vendor. The vendor then
must decide the claim no later than thirty (30) days after the additional
information is supplied or after the period of time allowed to supply it ends,
whichever is first. Written confirmation of the decision will be sent by the
vendor within fifteen (15) business days.
(V) For members with medical coverage through
Anthem-
(a) First and second level
pre-service, first and second level post-service, and concurrent claim appeals
must be submitted in writing to-
Anthem Blue Cross and Blue Shield
Attn: Grievance Department
PO Box 105568
Atlanta, Georgia 30348-5568 or by fax to (888) 859-3046
(b) Expedited
appeals may be submitted by calling (844) 516-0248 or by submitting a written
fax to (800) 368-3238.
C. The internal review process for adverse
benefit determinations relating to pharmacy and the Pharmacy Lock-In Program
consists of one (1) level of internal review provided by the pharmacy vendor.
(I) Pharmacy appeals. Pharmacy appeals and
Pharmacy Lock-In Program appeals must identify the matter being appealed and
should include the member's (and dependent's, if applicable) name, the date the
member attempted to fill the prescription, the prescribing physician's name,
the drug name and quantity, the cost of the prescription, if applicable, and
any applicable reason(s) relevant to the appeal including the reason(s) the
member believes the claim should be paid, the reason(s) the member believes
s/he should not be included in the Pharmacy Lock-In Program, and any other
written documentation to support the member's belief that the original decision
should be overturned.
(II) All
pharmacy appeals must be submitted in writing to-
Express Scripts
Attn: Clinical Appeals Department
PO Box 66588
St. Louis, MO 63116-6588 or by fax to (877) 852-4070
(III) All Pharmacy Lock-In Program
appeals must be submitted in writing to-
Express Scripts
Drug Utilization Review Program
Mail Stop HQ3W03
One Express Way
St. Louis, MO 63121
(IV) Pharmacy appeals will be reviewed by
someone who was not involved in the original decision and the reviewer will
consult with a qualified medical professional if a medical judgment is
involved. Pharmacy appeals will be responded to in writing to the member within
sixty (60) days for post-service claims and thirty (30) days for pre-service
claims from the date the vendor received the appeal request.
(V) The Pharmacy Benefit Manager will respond
to Pharmacy Lock-In Program appeals in writing to the member within thirty (30)
days from the date the Pharmacy Benefit Manager received the appeal
request.
D. Members may
seek external review only after they have exhausted all applicable levels of
internal review or received a final internal adverse benefit determination.
(I) A claimant or authorized representative
may file a written request for an external review within four (4) months after
the date of receipt of a final internal adverse benefit
determination.
(II) The claimant
can submit an external review request in writing to-
MAXIMUS Federal Services
Federal External Review Process (FERP)
3750 Monroe Ave., Suite 705
Pittsford, NY 14534 or by fax to (888) 866-6190 or to request a review online at externalappeal.cms.gov
(III) The claimant may call the toll-free
number (888) 866-6205 with any questions or concerns during the external review
process and can submit additional written comments to the external reviewer at
the mailing address above.
(IV) The
external review decision will be made as expeditiously as possible and within
forty-five (45) days after receipt of the request for the external
review.
(V) A claimant may make a
written or oral request for an expedited external review if the adverse benefit
determination involves a medical condition of the claimant for which the time
frame for completion of a standard external review would seriously jeopardize
the life or health of the claimant; or would jeopardize the claimant's ability
to regain maximum function; or if the final internal adverse benefit
determination involves an admission, availability of care, continued stay, or
health care item or service for which the claimant received services, but has
not been discharged from a facility.
3. For all internal appeals of adverse
benefit determinations, the plan or the vendor reviewing the appeal will
provide the member, free of charge, with any new or additional evidence or
rationale considered, relied upon, or generated by the plan or the vendor in
connection with reviewing the claim or the appeal and will give the member an
opportunity to respond to such new evidence or rationale before issuing a final
internal adverse determination.
(4) Except as otherwise expressly provided in
this rule, appeals of adverse determinations made by MCHCP may be appealed to
the board by sending or uploading the written appeal to one (1) of the
following:
Attn: Appeal
Board of Trustees
Missouri Consolidated Health Care Plan
PO Box 104355
Jefferson City, MO 65110 or by fax to (866) 346-8785 or online at www.mchcp.org
(5) In reviewing appeals,
notwithstanding any other rule, the board and/or staff may grant any appeals
when there is credible evidence to support approval under the following
guidelines:
(A) If a subscriber currently has
coverage under the plan, MCHCP may approve the subscriber's request to enroll
his/her newborn retroactively to the date of birth if the appeal is received
within three (3) months of the child's birth date. Valid proof of eligibility
must be included with the appeal;
(B) MCHCP may approve a subscriber's appeal
and not hold the subscriber responsible when there is credible evidence that
there has been an error or miscommunication through the subscriber's
payroll/personnel office, MCHCP, or MCHCP vendor that was no fault of the
subscriber;
(C) MCHCP may approve
an appeal to change the type of medical or vision plan that the subscriber
elected or defaulted to during the annual open enrollment period if the request
is made within thirty-one (31) calendar days of the beginning of the new plan
year, except that no changes will be considered for Health Savings Account
(HSA) Plan elections after the first MCHCP Health Savings Account contribution
has been transmitted for deposit to the subscriber's account. This guideline
may not be used to elect or cancel coverage or to enroll or cancel dependents.
If a subscriber has his/her premium collected pre-tax by qualified payroll
deduction through a cafeteria plan, changes may be approved if the reason given
is allowed by the cafeteria plan;
(D) MCHCP may allow one (1) reinstatement for
termination due to non-payment per lifetime of account. Payment in full for all
past and current premiums due for reinstatement must be included with the
appeal. MCHCP may allow one (1) additional reinstatement if the subscriber
submits an automatic withdrawal authorization;
(E) MCHCP may approve a subscriber's appeal
to terminate dental and/or vision coverage if the appeal is received within
thirty-one (31) calendar days of the beginning of the new plan year and if no
claims have been made or paid during the new plan year. If a subscriber has
his/her premium collected pretax by qualified payroll deduction through a
cafeteria plan, termination may be approved if the reason given is allowed by a
cafeteria plan;
(F) MCHCP may
approve an appeal regarding late receipt of proof-of-eligibility documentation
if the subscriber can provide substantiating evidence that it took an
unreasonable amount of time for the government agency creating the
documentation to provide subscriber with requested documentation;
(G) MCHCP may approve a subscriber's appeal
to enroll after a deadline due to late notice of loss of coverage from
subscriber's previous carrier if the appeal is within sixty (60) days from date
of late notice;
(H) MCHCP may
approve appeals, other than those relating to non-payment, if subscriber is
able to provide substantiating evidence that requisite information was sent
during eligibility period;
(I)
MCHCP may approve an appeal regarding plan changes retrospectively for
subscribers who are new employees within thirty (30) days of election of
coverage if no claims have been filed with the previous carrier. If a
subscriber has his/her premium collected pre-tax by qualified payroll deduction
through a cafeteria plan, changes may be approved if the reason given is
allowed by the cafeteria plan; and
(J) Once every five (5) years per account,
MCHCP may approve an appeal where a subscriber missed a deadline. MCHCP may
only approve an appeal under this guideline if the appeal is received within
sixty (60) days of the missed deadline. This guideline may not be used to
approve an appeal of a voluntary cancellation or an appeal of a deadline that
is statutorily mandated.
Notes
*Original authority: 103.059, RSMo 1992.
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