(A) Definitions.
(1) "Adverse benefit determination"
is a MyCare Ohio plan (MCOP)'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 MCOP;
(c) Denial, in whole or part, of
payment for a service not covered by medicaid, including a service denied
through the MCOP's prior authorization process as not medically
necessary;
(d) Denial of a request for a
specific MCOP-contracted non-agency or participant-directed waiver services
provider pursuant to paragraph (G) of rule
5160-58- 03.2 of the
Administrative Code;
(e) Failure to provide services in a
timely manner as specified in rules
5160-26- 03.1 and
5160-58- 01.1 of the
Administrative Code;
(f) Failure to act within the
resolution time frames specified in this rule; or
(g) 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 MCOP'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 member's rights
regardless of whether remedial action is requested. Grievance includes a
member's right to dispute an extension of time proposed by the MCOP to make an
authorization decision.
(4) "Notice of action (NOA)" is the
written notice an MCOP must provide to members when an MCOP adverse benefit
determination has occurred or will occur.
(B)(A)
NOA
Notice of
action (NOA) by
an MCOP.
a MyCare Ohio plan (MCOP).
(1) When an MCOP adverse benefit
determination has or will occur, the MCOP shall provide the affected member
with a NOA.
(2) The NOA shall
explain:
(a) The adverse benefit determination
the MCOP 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 MCOP;
(d) Information related
to exhausting the MCOP appeal;
(e)
The member's right to request a state hearing through the state's hearing
system upon exhausting the MCOP appeal
process;
(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 those services;
(i) The date the notice is issued;
(3) The following language and
format requirements apply to a NOA issued by an MCOP:
(a) It shall be provided in a manner and
format that may be easily understood;
(b) It shall explain that oral interpretation
is available for any language, written translation is available in prevalent
non-English languages as applicable, and written alternative formats may be
available as needed;
(c) It shall
explain how to access the MCOP's interpretation and translation services as
well as alternative formats that can be provided by the MCOP;
(d) When directed by ODM, it shall be printed
in the prevalent non-English languages of members in the MCOP's service area;
and
(e) It shall be available in
alternative formats, and in an appropriate manner, taking into consideration
the special needs of members, including but not limited to members who are
visually limited and members who have limited reading proficiency.
(4) An MCOP shall issue a NOA
within the following time frames:
(a) For a
decision to deny or limit authorization of a requested service, the MCOP shall
issue a NOA simultaneously with the MCOP's decision.
(b) For reduction, suspension, or termination
of services prior to the member receiving the services previously authorized by
the MCOP, the MCOP 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 MCOP 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, 2022), the MCOP 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 MCOP shall give notice
simultaneously with the MCOP's action to deny the claim, in whole or part, for
a service that is not covered by medicaid, including a service that was
determined through the MCOP's prior authorization process as not medically
necessary.
(d) For denial of a
request for a provider pursuant to paragraph (A)(1)(d) of this rule, the MCOP
shall give notice simultaneously with the MCOP's decision.
(e) For untimely prior authorization, appeal,
or grievance resolution, the MCOP shall give notice simultaneously with the
MCOP becoming aware of the untimely resolution. Service authorization decisions
not reached within the time frames specified in rules
5160-26-03.1 and 5160-58-
01.1 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)(B) Grievances to an
MCOP.
(1) A member may file a grievance with
an MCOP 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 MCOP shall
acknowledge the receipt of each grievance to the member filing the grievance.
Oral acknowledgment by an MCOP 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
MCOP 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 all other grievances that are not regarding access to services.
(4) At a minimum, an MCOP shall
provide oral notification to the member of a grievance resolution. If an MCOP
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 MCOP's resolution.
(5) If an MCOP's resolution to a grievance is
to affirm the denial, reduction, suspension, or termination of a service,
denial of a provider pursuant to paragraph (A)(1)(d) of this rule, or billing
of a member due to the MCOP's denial of payment for that service, the MCOP
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)(C) Standard appeal to
an MCOP.
(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 by a written appeal. An MCOP 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 MCOP must
begin processing the appeal upon receipt of the written consent.
(3) An MCOP 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 MCOP within three business days of
receipt of the appeal.
(4) An MCOP
shall provide members a 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, and any other documents and
records, and any new or additional evidence considered, relied upon or
generated by an MCOP, or at the direction of an MCOP, in connection with the
appeal of the adverse benefit determination.
(5) An MCOP shall consider the member, the
member's authorized representative, or an estate representative of a deceased
member as parties to the appeal.
(6) An MCOP 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
MCOP 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; and
(ii) How to request the continuation of
benefits.
(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 MCOP's interpretation and translation services as well as
alternative formats that can be provided by the MCOP.
(9) For appeal resolutions decided in favor
of the member, an MCOP 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)(D) Expedited appeals
to an MCOP.
(1) An MCOP shall establish and
maintain an expedited review process to resolve appeals when the member
requests and the MCOP determines, or the provider indicates in making the
request on the member's behalf or supporting the member's request, that taking
the time for a standard resolution could seriously jeopardize the member's
life, physical or mental or health or ability to attain, maintain, or regain
maximum function.
(2) In utilizing
an expedited appeal process, an MCOP shall comply with the standard appeal
process specified in paragraph (D) of this rule, except the MCOP 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 MCOP 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; and
(f)
Ensure punitive action is not taken against a provider who requests an
expedited resolution or supports a member's appeal.
(g) Notify ODM within one business
day of any appeal that meets the criteria for expedited resolution as specified
by ODM.
(3) If an MCOP denies the request for
expedited resolution of an appeal, the MCOP 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; and
(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)(E) Grievance and
appeal resolution extensions.
(1) A member
may request the time frame for an MCOP to resolve a grievance or standard or
expedited appeal be extended up to fourteen calendar days.
(2) An MCOP may request that the time frame
to resolve a grievance or standard or expedited appeal be extended up to
fourteen calendar days. The following requirements apply:
(a) The MCOP shall seek such an extension
from ODM prior to the expiration of the standard or expedited appeal or
grievance resolution time frame;
(b) The MCOP 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 MCOP
shall immediately give the member written notice of the reason for the
extension and the date a decision shall be made.
(3) The MCOP shall maintain documentation of
any extension request.
(G)(F) Access to state's
hearing system.
(1) In accordance with
42 CFR
438.402 (October 1, 2022), members may
request a state hearing only after exhausting the MCOP's appeal process. If an
MCOP fails to adhere to the notice and timing requirements for appeals set
forth in this rule, the member is deemed to have exhausted the MCOP appeal
process and may request a state hearing.
(2) When required by paragraph (D)(8) of this
rule, and in accordance with division 5101:6 of the Administrative Code, an
MCOP shall notify members, and any authorized representatives on file with the
MCOP, of the right to a state hearing subject to the following requirements:
(a) If an MCOP appeal resolution upholds the
denial of a request for the authorization of a service, in whole or in part,
the MCOP shall simultaneously issue the "Notice of Denial of Medical Services
By Your Managed Care
Plan"
Entity" (ODM 04043).
(b) If an MCOP appeal resolution upholds the
decision to reduce, suspend, or terminate services prior to the member
receiving the services as authorized by the MCOP, the MCOP shall issue the
"Notice of Reduction, Suspension or Termination of Medical Services By Your
Managed Care
Plan"
Entity" (ODM 04066).
(c) If an MCOP appeal resolution upholds the
denial of a request for the authorization to receive waiver services from a
provider pursuant to paragraph (A)(1)(d) of this rule, the MCOP shall
simultaneously issue the required notice of state hearing rights.
(d) If an MCOP learns a member has been
billed for services received by the member due to the MCOP's denial of payment,
and the MCOP upholds the denial of payment, the MCOP shall immediately issue
the "Notice of Denial of Payment for Medical Services By Your Managed Care
Plan"
Entity"
(ODM 04046).
(3) The
member or the member's authorized representative may request a state hearing
within
one hundred twenty
ninety 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).
(4) There are no state hearing rights for a
member terminated from an MCOP pursuant to an MCOP-initiated membership
termination
as permitted in
in accordance with rule
5160-58-02.1 of the Administrative
Code.
(5) Following the bureau of
state hearing's notification to an MCOP that a member has requested a state
hearing, the MCOP shall:
(a) Complete the
"Appeal Summary for Managed Care
Plans
Entities" (ODM 01959) 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 MCOP'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 MCOP is notified the member's state
hearing request was received within fifteen days from the date of the appeal
resolution.
(6) An MCOP
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) sent to
the MCOP by the bureau of state hearings.
(7) An MCOP shall comply with the state
hearing decision provided to the MCOP via the "State Hearing Decision" (JFS
04005). If the state hearing decision sustains the member's appeal, the MCOP
shall submit the information required by the "Order of Compliance" (JFS 04068)
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 MCOP 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)(G) Continuation of
benefits while the appeal to an MCOP or state hearing are pending.
(1) Unless a member requests that previously
authorized benefits not be continued, an MCOP shall continue a member's
benefits when all the following conditions are met:
(a) The member requests an appeal within
fifteen days of the MCOP 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 MCOP
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 MCOP
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 MCOP's original
adverse benefit determination, at the discretion of ODM, the MCOP may recover
the cost of the services furnished to the member while the appeal and/ or state
hearing was pending.
(I)(H) Other duties of an
MCOP regarding appeals and grievances.
(1) An
MCOP shall give members all reasonable assistance filing a grievance, an
appeal, or a state hearing request including but not limited to:
(a) Explaining the MCOP'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 grievance
system through a toll-free number with text telephone yoke (TTY) and
interpreter capability.
(2) An MCOP 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, the
MCOP shall take into account all comments, documents, records, and other
information submitted by the member or their representative without regard to
whether such information was submitted or considered in the initial adverse
benefit determination.