048-47 Wyo. Code R. §§ 47-22 - Grievance and Complaints

(a) The CME shall have a system in place for enrollees or providers acting on behalf of enrollees to access a grievance process, an appeal process, and access to the Department's fair hearing system. The CME's grievance procedure shall meet the following requirements:

(i) Notice of the CME's grievance procedure shall be sent to enrollees once the Department informs the CME of the youth's eligibility as a program enrollee;

(ii) The CME's grievance and one-level appeal process must adhere to the timeframes specified in 42 C.F.R. § 438.400 and § 438.424.

(iii) An enrollee has sixty (60) calendar days from the date on the adverse action notice to file an oral or written request

(iv) The CME shall acknowledge in writing, via certified mail, the receipt of a written or oral grievance or complaint within five (5) working days of receipt;

(v) The CME shall prepare and present a proposed resolution to the complaint within forty-five (45) calendar days from the date the CME receives the grievance. If the CME's proposed resolution is not accepted by the enrollee or entity acting on behalf of the enrollee they may file a request for continuation of benefits within ten (10) calendar days of receipt of the proposed resolution or the intended effective date of the adverse action notification, whichever is later. The CME has thirty (30) calendar days to review and respond to the appeal.

(vi) An enrollee may request a State fair hearing after receiving notice under 42 C.F.R. § 438.408 that the adverse benefit determination is upheld by the CME.

(vii) If the CME fails to adhere to the notice and timing requirements in § 438.408, the enrollee is deemed to have exhausted the CME's appeals process. The enrollee may initiate a State fair hearing.

Notes

048-47 Wyo. Code R. §§ 47-22

Adopted, Eff. 9/23/2019.