Grievance, Appeal, and State Fair Hearing Process

Definitions

The Grievance, Appeal, and State fair hearing process for the PMHCP is mandated by Minnesota Statutes, Sections 256.045, Subd. 3a, and 62D.11, 42 CFR 438, Subpart F, and Minnesota Statutes 62Q.68 through 62Q.73. State fair hearings are conducted by a Department of Human Services Judge.

Any MCO Action or Grievance may be reviewed at a State fair hearing.

MCO Grievance System - The grievance and appeal process is explained in each of the following communications:

· Evidence of Coverage (EOC)

· Notice of Rights and Responsibilities (DHS-3214)

· Denial/Termination/Reduction (DTR) Notice

The State fair hearing process is available to all Minnesota Health Care Program enrollees. The enrollee has the right to request a State fair hearing due to:

· Participation in the PMHCP

· Delivery of health services

· Denial in full or part of a claim or service

· Failure of the MCO to act within required timelines for service authorizations, grievance and appeals, or

· Any other Action or Grievance

A recipient does not have to exhaust the MCO grievance or appeal process before filing a State fair hearing request.

Notification Requirements

Each PMHCP participant receives a Notice of Rights and Responsibilities with the initial enrollment packet and with each notice of open enrollment and at least one other time - usually with legislative change notice.

The state ombudsman or county staff may send the rights notice to enrollees who contact them for grievance or appeal resolution.

An explanation of the grievance and appeal process is included in the MCO member materials.

Every MCO member receives an Evidence of Coverage (EOC). The EOC explains the MCO’s and the State's grievance, appeal and State fair hearing procedures and the right to a second medical opinion within the plan.

When an MCO denies, terminates or reduces a service or denies payment for a service, the MCO must send the member a written notice. This notice, commonly referred to as a DTR, must include:

A clear detailed description in plain language of the basis for the DTR and of the enrollee’s rights

· The Action that the MCO has taken or intends to take

· The type of service or claim that is being denied, terminated, or reduced

· The reasons for the Action

· The specific federal, state regulations or MCO policies that support or require the Action

· The date the DTR was issued

· The effective date of the Action. If it results in a reduction or termination of on-going or previously authorized services

· The enrollee’s right (or provider on behalf of the enrollee with the enrollee’s written consent) to file an appeal with MCO

· The enrollee’s right to file a request for a State fair hearing without first exhausting the MCO’s Grievance or Appeal procedures, or up to 30 days after the MCO’s final determination of the Grievance or Appeal

· The process the enrollee must follow in order to exercise these rights

· The circumstances under which expedited resolution is available and how to request it for an Appeal or State fair hearing

· The enrollee’s right to continuation of benefits, how to request that benefits be continued, and under what circumstances the enrollee may have to pay for these services if the enrollee files an Appeal at the MCO or requests a State fair hearing

· The Notice of Member Rights

· The requirements and timelines for filing an MCO Appeal pursuant to 42 CFR 438.402

· The right to seek an expert medical opinion from an external organization in cases of medical necessity at the state’s expense, for consideration at State fair hearings

· A language block in the languages specified by MN Statutes, §256B.69, Subd. 27, in a format determined by the State

· A phone number at the MCO where enrollees may call to obtain information about the DTR, including how to receive a translation of the notice into Spanish, Hmong, Russian, Somali, or Vietnamese.

Role and Responsibility of County

Role of County

Each PMHCP county must have staff available to assist PMAP enrollees in resolving problems regarding participation in a MCO. County staff must also be available to assist enrollees in resolving complaints through informal and/or formal mechanisms. An advocate must be available to assist in the grievance, appeal and State fair hearing process.

County Advocate Responsibility

The general responsibilities of the county advocate are:

· Assist the enrollee to articulate his/her complaint and understand the options available to resolve the complaint.

· Assist the enrollee in making an informed decision to pursue options which resolve the problem.

County Advocate Involvement

When an enrollee contacts the county, the county advocate should do the following:

Gather initial information from the enrollee to learn more about the issue.

· Verify eligibility status, date of enrollment in the MCO, etc.

· Determine what remedy the enrollee seeks, i.e., payment of a bill, authorization of a specific service, etc.

· Send a letter to the enrollee to explain the role of the county advocate and information about the MCO grievance and appeal process and the State fair hearing process.

· If the advocate is assisting the recipient; file a MCO grievance or appeal, or request a State fair hearing, have the enrollee sign an authorization form which gives the advocate permission to assist the enrollee.

· If requested, assist the enrollee in gathering information necessary to resolve the problem, formally or informally. This may involve:

· contacting the MCO,

· gathering pertinent information, or

· contacting other parties, e.g., providers.

· Assist the enrollee in writing a letter to the MCO, if a written grievance or appeal has not been filed. The letter should include the words "PMHCP" and “grievance” or “appeal,” and the specific remedy requested. Copy the letter to the county, and the ombudsman. DHS will monitor the MCO's response.

· The enrollee may or may not decide to file a complaint with the MCO. The county advocate may continue to help the enrollee compile information pertinent to the complaint and verify the facts of the complaint with all parties, e.g., MCOs, providers, social workers. Frequently there are misunderstandings or lack of communication among the parties involved in the complaint. Clarification of misunderstandings at this point often result in a resolution of the complaint before filing a grievance, appeal or State fair hearing request.

· If a resolution does not appear likely without a State fair hearing, or the enrollee wishes to file a request for a State fair hearing through the Department immediately, the enrollee must complete and sign the State Appeal Form (DHS-0033) and the Request for Release of Medical Information form.

· The county advocate must send the ombudsman the signed appeal form and the State Agency Appeal Summary. The county advocate, financial worker, or other county personnel must complete the State Agency Appeal Summary. The appeal form and summary are received by the ombudsman and forwarded to the DHS Appeals Unit. The ombudsman office enters all managed care State fair hearing requests into a tracking system to monitor the type and outcome of all hearings.

· An expedited MCO grievance or appeal, or a State fair hearing, may be requested by the recipient, the provider on behalf of the recipient, and/or the county advocate when a resolution is needed without delay. To request an expedited grievance or appeal indicate "request expedited appeal" at the top of the appeal form. The MCO must take final action within 72 hours from receipt of the request from the enrollee in situations where taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, the criteria of 42 CFR 438.410(a). The State must take final action within 3 working days of receipt of the file from the MCO or a request from the enrollee which meets the criteria of 42 CFR 438.410 (a) Upon request of the client, arrangements are made for telephone hearings.

MCO Internal Complaint Process

Each MCO must identify in their EOC a description of all grievance, appeal, and State fair hearing procedures available to enrollees, including the MCO’s grievance and appeal procedures. The MCO’s internal complaint procedure must consist of a grievance process and an appeal process for reviewing enrollee complaints. The MCO’s grievance system must include adjudication of grievances or appeals made by providers on behalf of enrollees, with the enrollee’s consent 42 CFR 38.402(b)(ii).

MCO Grievance Process

The enrollee, or the provider acting on behalf of the enrollee with the enrollee’s written consent, may file a grievance within 90 days of a matter involving an enrollee’s dissatisfaction with the health care received. A grievance may be filed orally or in writing.

Oral Grievances must be resolved within 10 days of receipt. Written Grievances must be resolved within 30 days of receipt.

The MCO may extend the timeframe by an additional fourteen days if the enrollee or the provider requests the extension, or if the MCO justifies a need for additional information and how the extension is in the enrollee’s interest. The MCO must provide written notice of the reason for the extension within 30 days.

MCO Appeal Process

The enrollee, or the provider, acting on behalf of the enrollee with the enrollee’s written consent, may file an appeal within 90 days of the DTR or for any other action taken by the MCO. An appeal may be filed orally or in writing. If the appeal is filed orally the MCO must offer to assist the enrollee, or the provider filing on behalf of the enrollee, in completing a written appeal.

The MCO must resolve each appeal as expeditiously as the enrollee’s health requires, and no later than 30 days, including resolution of those oral appeals which were not reduced to writing. The MCO may extend the timeframe for standard appeals by an additional fourteen days if the enrollee or the provider requests the extension, or if the MCO justifies a need for additional information and how the extension is in the enrollee’s interest. The MCO must provide written notice of the reason for the extension within 30 days.

State Fair Hearing Process

The State appeal process, authorized by Minnesota Statutes 256.045 gives PMHCP enrollees the right to appeal issues regarding mandatory participation in PMHCP and services denied, terminated, or reduced.

Types of State Fair Hearings

There are two types of State fair hearings for the PMHCP:

· Administrative Fair Hearing

· Appeal of mandatory participation

· Request to change MCOs - involves an enrollee's desire to change MCOs outside the authorized time frames

· Service Hearing - involves an enrollee’s dispute over an MCO’s denial, termination or reduction of services, denial of payment for a service, or any other negative action by the MCO

Administrative State Fair Hearing of Mandatory Participation

A PMAP enrollee may request a State fair hearing regarding mandatory participation in the PMHCP and request to remain on or return to fee-for-service MA. Enrollee’s should be aware that there is no statutory language that allows exclusion of individuals who are not part of an excluded group. Prepaid MinnesotaCare enrollees may appeal mandatory participation, but should be aware that there are no excluded groups under PMCRE.

Recipients who have not selected a MCO, pending results of a State fair hearing , must select or be assigned to a MCO according to the usual procedure.

MA recipients who wish to request a State fair hearing regarding mandatory participation should be referred to the county advocate or State ombudsman. The advocate or ombudsman can describe the State fair hearing procedure and/or assist in exploring other options, i.e., changing MCOs when the option is available or for good cause.

The recipient can send a letter requesting a State fair hearing or request the appeal form from:

· The county office

Managed Health Care Ombudsman MN Department of Human Services PO Box 64249 St. Paul, MN 55155-0249 (651)431-2660 or 1/800-657-3729

State Appeals Office MN Department of Human Services PO Box 64941 St. Paul, MN 55155-0941 Fax: (651)431-7523 (Attn: New Appeal)

MinnesotaCare MN Department of Human Services PO Box 64838 St. Paul, MN 55164-0838 (651)297-3862 or 1/800-657-3672

When the recipient returns their request for a State fair hearing, the State ombudsman will log the request into the database and forward it to the Department’s Appeals Unit. A PMHCP representative from the Department will submit written evidence regarding the authority to mandate enrollment in a MCO. Within ninety (90) days the enrollee will receive written notification regarding the outcome of the State fair hearing.

The Department’s Appeals unit usually schedules a hearing within two to three weeks of receiving the State fair hearing request. A Human Services Judge from the Department’s Appeals unit conducts the hearing. The hearing may be by phone or in person. The enrollee must attend the scheduled hearing or cancel before the hearing date, or she/he will lose the right to a State fair hearing.

The enrollee has a right to legal assistance. Legal Aid telephone numbers should be available to the enrollee when the initial request for a State fair hearing is made.

Administrative State Fair Hearing to Change MCO

An enrollee may file for an administrative State fair hearing to request a change of MCO outside the first year or 90 day change options or the open enrollment period for the following reasons:

· Inaccessibility - the enrollee files an appeal to change MCOs because travel time to the primary care provider:

a. in the metro area, over thirty (30) minutes,

b. in the metro area, less than thirty (30) minutes, but considered excessive by enrollee.

c. in the non-metro area, considered excessive by community standards.

NOTE: Travel time in the metro area can usually be verified by the Metro Transit.

Telephone number (612) 373-3333, www.metrotransit.org.

Tell the information representative:

· The enrollee’s address

· Where the enrollee would be going (name and address of primary clinic)

· Time of travel (non-peak hours)

· The enrollee's MCO was incorrectly designated due to local agency error, e.g., clerical error. Contact your DHS Enrollment Coordinator.

· Good Cause

Service Related State Fair Hearing

An enrollee may request a State fair hearing regarding, but not limited to:

· A MCO's decision to deny, terminate or reduce services

· A MCO's resolution of a grievance or appeal which is not in favor of the member

· Other problems regarding service from a MCO

· Bills incurred by the enrollee, for which payment was denied by the MCO

· Any other ruling of a prepaid MCO

If the State fair hearing involves a service issue, the enrollee may be referred to a County Advocate, Ombudsman or other personnel who can assist in resolving the complaint. A State fair hearing request must be filed within 30 days after the MCO sends a notice for denial, termination, or reduction of services and within 90 days, if there is good cause for the delay pursuant to MN Statutes, Section 256.045.

Role of County Advocate

If a PMAP enrollee decides to file a State fair hearing request, the following actions must be taken by the county advocate.

· Explain the State fair hearing process.

· The hearing is held either at a county office or by telephone. A DHS Human Services Judge conducts the hearing.

· The enrollee has the right to representation by a family member, friend, social worker, advocate, attorney or other interested party.

· The enrollee, with the assistance of the county advocate, is responsible for providing evidence to support the case.

· The county advocate must send the following forms to the enrollee to complete and sign:

· Appeal Form (DHS-0033)

· Authorization to Release Medical Information.

· The county advocate or the enrollee must send the signed forms to the State Ombudsman or the Appeals Office and keep a copy of each. The county advocate must also send a completed copy of the State Agency Appeal summary (DHS-0035) to the ombudsman.

· The county advocate must inform the MCO about any grievance, appeal, or State fair hearing that relates to service. The county must notify the MCO when a State fair hearing request is filed without using the MCO's grievance or appeal process. (This gives the MCO an opportunity to consider its decision before the hearing).

· The county advocate may help the petitioner:

· Gather documentation or evidence, such as, case summary, medical records pertaining to the case (e.g., doctor orders, hospital and clinic records), letters from providers letters of denial from the MCO, case notes, treatment plan, diagnostic evaluations, prognosis, etc. the MCO's Evidence of Coverage, PMHCP rules and appropriate statute citations.

· Obtain witnesses, and

· If necessary, help the enrollee prepare opening and closing remarks for the hearing.

· The petitioner must submit all evidence to the Department State fair hearing referee before or at the time of the hearing.

· If requested, the county advocate may assist or represent the enrollee at the hearing.

· The petitioner may also need assistance after a ruling is made in the case

Role of Petitioner

The petitioner is the enrollee who files a grievance, appeal, or State fair hearing request. It is the responsibility of the petitioner to:

· Have a clear understanding of the issue(s) that need resolution.

· Understand what remedy is being requested.

· Be prepared to articulate the facts surrounding the issue(s) or request a representative (e.g., an advocate or legal aid) to help.

· Provide evidence to support the appeal/State fair hearing by obtaining all pertinent records, letters from providers, etc.

· Notify the State fair hearing referee in advance if attendance at the scheduled hearing is not possible.

· Use the services of the county advocate, State ombudsman or legal assistance, if needed, with any part of the grievance, appeal, or State fair hearing process.

State Ombudsman

Role of State Ombudsman

The Commissioner of Human Services designates the State ombudsman to advocate for persons required to enroll in prepaid MCOs (Minnesota Statutes 256B.69, Subd. 6). The grievance, appeal, and State fair hearing procedures ensure necessary medical services are provided by the MCO directly or by referral to an appropriate provider.

Responsibilities of Department Ombudsman

The ombudsman may assist enrollees in resolving service related problems with the MCO. If requested by the enrollee, the ombudsman will investigate the enrollee's complaint and attempt to resolve the problem informally. The ombudsman serves as an intermediary between the enrollee and the MCO.

The ombudsman will explain to the enrollee:

· Grievance, appeal, and State fair hearing options,

· How to file a grievance, appeal, or State fair hearing request,

· How to obtain a second opinion from the MCO,

· How to file an expedited appeal or State fair hearing request, and

· How the grievance, appeal, and State fair hearing process functions.

If a complaint cannot be resolved informally, the ombudsman may assist the enrollee in filing a grievance, appeal, or State fair hearing request.

Relationship between the MCO and the Ombudsman

When a MCO denies, terminates, or reduces a health service or denies payment for a service, it must send notification to the enrollee of the right to file a MCO appeal or State fair hearing request with the State. This notice must include the phone number of the State Ombudsman.