411-045-0130 - Appeal Process

411-045-0130. Appeal Process

(1) All denials, reductions, or terminations of services or service coverage by the PACE program must be in writing in accordance with Section (3) of this rule. PACE programs must make available to all PACE staff and contracted providers information concerning client notices, appeals and hearings processes.

(2) When the PACE program authorizes a course of treatment or covered service, but subsequently acts (as defined in 42 CFR 431.201) to terminate, discontinue, or reduce the course of treatment or a covered service, the PACE program must mail a written notice to the participant at least ten (10) working days before the date of the termination or reduction of the covered service unless there is documentation that the participant had previously agreed to the change as part of the course of treatment.

(3) The written client notice must be a Department approved format and is to be used for all denials, reductions, or terminations of services and denials of claims payment. The notice must inform the PACE participant of the following:

(a) Relevant information to include but is not limited to the following:

(A) Date of notice;

(B) Program name;

(C) Primary Care Provider's name;

(D) Participant's name and ID number;

(E) Date of Request/Service;

(F) Service or Item Requested or provided;

(G) Who Requested or Provided the item or service;

(H) Effective Date of Action;

(b) Reasons for the action to include the following:

(A) Treatment is not covered, item requires pre-authorization and it was not pre-authorized;

(B) It is not medically appropriate;

(C) Service or item received in an emergency care setting and does not qualify as an emergency service;

(D) Person was not a participant at the time of the service or is not a participant at the time of a requested service.

(E) The provider is not on the panel and person did not obtain prior approval;

(c) The PACE participant's right to file an appeal with the plan and request an administrative hearing with the Department including attaching the Notice of Hearing Rights (OMAP 3030) that includes a statement that the PACE participant may request continuation of benefits until a decision is rendered; and

(d) The telephone number to contact for additional information.

(4) The PACE program will have the following responsibilities in relation to section (2) of this rule:

(a) The PACE program must continue services if the PACE participant or PACE participant's representative requests an administrative hearing before the effective date of the client notice and requests that services be continued. The service must be continued until whichever of the following occurs first (but in no event should exceed ninety (90) days from the date of the participant's request for an administrative hearing):

(A) The current authorization expires; or

(B) A decision is rendered about the appeal; or

(C) The participant is no longer eligible for PACE.

(b) The PACE program must notify the PACE participant or PACE participant's representative in writing that it is continuing the service. The notice must inform the PACE participant or PACE participant's representative that if the hearing is resolved against the PACE participant, the cost of any services continued after the effective date of the client notice may be recovered from the PACE participant pursuant to 42 CFR 431.230(b);

(c) The PACE program must reinstate services if:

(A) The PACE program takes an action without providing the required notice and the PACE participant requests a hearing;

(B) The PACE program does not provide the notice in the time required under section (2) of this rule and the PACE participant requests a hearing within 10 days of the mailing of the notice of action; or

(d) The PACE program must promptly correct the action taken up to the limit of the original authorization, retroactive to the date the action was taken, if the hearing decision is favorable to the PACE participant, or the Department or the PACE program decides in the PACE participant's favor before the hearing even if the PACE participant has lost eligibility after the date the action was taken.

(5) If an appeal is made to a PACE program's staff person the appeal must be recognized by the PACE program, forwarded to the PACE staff person responsible for appeals, and answered in writing:

(a) The PACE program's staff person must notify the PACE participant or the participant's representative in accessible format of the decision that denied, discontinued or reduced the service(s) or coverage within five (5) working days. The decision letter must include at least the elements included in Section (3) of this rule;

(b) A copy of the Notice of Hearing Rights (OMAP 3030) and Administrative Hearing Request (AFS 443) must be attached.

(SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 2-2005, f. & cert. ef. 1-4-05)

Stat. Auth.: ORS 410.090

Stats. Implemented: ORS 410.070

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