Sec. 10.67.09.05. MCO Appeal Process for Enrollees

A. An MCO's appeal process shall:

(1) Require that an enrollee, or a provider acting on the enrollee’s behalf, file an appeal within 60 days from the date on the MCO’s notice of action;

(2) Include procedures for acknowledging receipt of appeals within 5 business days;

(3) Permit an enrollee to request an appeal either orally or in writing;

(4) Provide that oral requests for appeal are considered the initiation of the appeal to establish the earliest possible filing date, and are confirmed in writing, unless the enrollee, their representative, or the provider requests an expedited appeal;

(5) Provide reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing, and in the case of expedited appeals, the MCO shall inform the enrollee of the limited time available for the enrollee to present this evidence;

(6) Provide the case file upon request to the enrollee and the enrollee's representative, free of charge and sufficiently in advance of the resolution time frame for appeals, which includes:

(a) Medical records;

(b) Other documents and records; and

(c) Any new or additional evidence considered, relied upon, or generated by the MCO in connection with the action.

(7) Allow a provider or authorized representative acting on behalf of an enrollee to file an appeal with the enrollee’s written consent;

(8) Consider the enrollee, the enrollee's representative, or the estate representative of a deceased enrollee as parties to the appeal;

(9) Establish and maintain an expedited review process, when the MCO determines or the provider indicates that taking the time for a standard resolution could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function; and

(10) Ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal.

B. Resolution.

(1) Except for expedited appeals as described in §C, an MCO shall resolve each appeal and provide notice of resolution, as expeditiously as the enrollee’s health condition requires, and unless extended pursuant to §B(2) of this regulation, within 30 days from the day the MCO receives the appeal.

(2) The time frames in §B(1) of this regulation may be extended up to 14 calendar days if:

(a) The enrollee requests the extension; or

(b) The MCO shows, upon the Department's request, that there is a need for additional information and how the delay is in the enrollee's interest.

(3) For any extension not requested by the enrollee, the MCO shall:

(a) Give the enrollee written notice; and

(b) Make reasonable efforts to give the enrollee verbal notice of the reason for the delay.

(4) Continuation of Benefits. The MCO shall continue the enrollee’s benefits pending the outcome of the appeal if all of the following occur:

(a) The enrollee timely files for continuation of benefits;

(b) The appeal is filed timely, meaning on or before the later of the following:

(i) Within 10 days of the MCO mailing the notice of action; or

(ii) The intended effective date of the MCO's proposed action;

(c) The appeal involves the termination, suspension, or reduction of a previously authorized service;

(d) The services were ordered by an authorized provider; and

(e) The authorization period has not expired.

(5) If the MCO continues or reinstates the enrollee's benefits while the appeal is pending, the benefits shall continue until one of the following occurs:

(a) The enrollee withdraws the appeal;

(b) The enrollee fails to request a State fair hearing and continuation of benefits within 10 days after the MCO sends the notice of an adverse resolution to the enrollee’s appeal; or

(c) A State fair hearing decision adverse to the enrollee is made.

(6) If the MCO or State fair hearing officer reverses a decision to deny, limit, or delay services, the MCO shall authorize or provide the disputed services promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours of the date the MCO receives the reversal.

C. Expedited Appeals.

(1) An expedited resolution may be approved when the MCO determines or the provider indicates that taking the time for a standard resolution could seriously jeopardize:

(a) The enrollee’s life;

(b) The enrollee’s physical or mental health; or

(c) The enrollee’s ability to attain, maintain, or regain maximum function.

(2) Expedited appeals shall be resolved as expeditiously as the enrollee’s health condition requires but no later than 72 hours after the MCO receives the appeal.

(3) If the MCO denies a request for expedited resolution of an appeal, the MCO shall:

(a) Transfer the appeal to the standard time frame of not longer than 30 days from the day the MCO receives the appeal with a possible 14-day extension as described in §B(2) of this regulation; and

(b) Make reasonable efforts to give the enrollee prompt verbal notice of the denial of expedited resolution and provide a written notice within 2 calendar days.

D. Notification.

(1) The MCO shall provide written notice of resolution which includes:

(a) The results and date of the appeal resolution;

(b) The reasons for the action;

(c) For decisions not wholly in the enrollee’s favor:

(i) The right to request a State fair hearing;

(ii) How to request a State fair hearing;

(iii) The right to continue to receive benefits pending a hearing;

(iv) How to request the continuation of benefits; and

(v) A statement that the enrollee may be liable for the cost of any continued benefits if the MCO's action is upheld in a hearing.

(2) For notice of an expedited resolution, in addition to requirements listed in §D(1) of this regulation, the MCO shall also make reasonable efforts to provide oral notice of the decision.

E. If an MCO fails to adhere to the notice and timing requirements, as described in §§A-D of this regulation, the enrollee is deemed to have exhausted the MCO’s appeals process and may initiate a State fair hearing.

F. State Fair Hearing.

(1) An enrollee may exercise State fair hearing rights pursuant to the Department’s regulations and State Government Article, §10-201 et seq., Annotated Code of Maryland, subject to the requirements of this regulation.

(2) An enrollee may request a State fair hearing for an MCO appeal resolution after first exhausting the MCO’s appeal process by appealing to the Office of Administrative Hearings using the process specified in COMAR 10.01.04.

(3) An enrollee shall file for a State fair hearing within 120 days from the date the MCO provides on the written notice of appeal resolution.

(4) The parties to an appeal to the Office of Administrative Hearings under this section are the:

(a) MCO;

(b) Enrollee; and

(c) Enrollee’s representative or the personal representative of a deceased enrollee’s estate.

(5) The MCO shall provide documentation regarding medical determinations to enrollees and the Office of Administrative Hearings as required by COMAR 10.01.04 and other applicable law.

(6) The MCO shall continue the enrollee’s benefits pending the outcome of the State fair hearing if all of the following occur:

(a) The enrollee files for continuation of benefits within 10 days of the MCO upholding its action;

(b) The State fair hearing request is filed timely, meaning on or before the later of the following:

(i) 10 days from the date on the MCO’s notice of appeal resolution; or

(ii) The intended effective date of the MCO's proposed action;

(c) The State fair hearing involves the termination, suspension, or reduction of a previously authorized service;

(d) The services were ordered by an authorized provider; and

(e) The authorization period has not expired.

(7) If the MCO continues or reinstates the enrollee's benefits while the State fair hearing is pending, the benefits shall continue until one of the following occurs:

(a) The enrollee withdraws the State fair hearing; or

(b) A State fair hearing decision adverse to the enrollee is issued by the Office of Administrative Hearings.

(8) The final decision of the Office of Administrative Hearings is appealable to the circuit court, and is governed by State Government Article, §10-201 et seq., Annotated Code of Maryland, and the Maryland Rules.

G. The Department may order an MCO to provide a benefit or service based on its evaluation of the MCO’s action.