Subject to change. Summary only; does not supersede manuals and formal notices and publications. Consult www.partnersbhm.org and appropriate Partners for most recent information or with questions.

Gain a better understanding of the Peer Review Process

Gain a greater understanding of LME/MCO Due Process

Gain knowledge about Provider roles in the Reconsideration and Appeals processes

Learn more about the timelines of the Reconsideration/Appeal processes

Grievance System. 42 CFR 438.402 3 Levels: ◦ Grievance Process Conducted by LME/MCO Called “Grievance” in North Carolina

◦ Appeal Process Conducted by LME/MCO Called “Local Reconsideration” in North Carolina

◦ State Fair Hearing Hearing is conducted by the Office of Administrative Hearing (OAH) Called “Appeal” in North Carolina

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Robust and Multi-DoorFour Dispute Types:

• Consumer: any “entitlement” belongs to consumer1. Medicaid Appeals: Medicaid services denied,

terminated, suspended or reduced2. Non-Medicaid Appeals: consumer services funded by

state, county and other sources3. Provider Disputes: TNOs, terminations, RADSE –

any “entitlement” belongs to provider4. Grievances (anyone): most any other complaint or

dispute

2/1/2017Due Process Overview 5

Grievances: 90 days Reconsideration ◦ Consumer has 30 days to request appeal (“reconsideration”) of LME/MCO

action◦ Standard: 30 days◦ Expedited: 72 hours with written notification within 3 calendar days of

decision State Fair Hearing◦ Any appeal (“reconsideration”) not decided wholly in favor of the consumer,

must include notice of State Fair Hearing (“appeal”) rights◦ Consumer has 30 days to request State Fair Hearing from the date of the

appeal (“reconsideration”) decision◦ After 30 days, LME/MCO appeal (“reconsideration”) decision becomes final

42 CFR 438.408; URAC HUM 38 &39; NCGS, Chapt. 108D

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Decision (NOD or NOA)

Peer-to-Peer (P2P)

Independent R

econsideration

OAH & Mediation

Judicial System (Courts)

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• Services denied, suspended, terminated or reduced• From internal (blue) to external (purple)• Time, process details heavily governed• Documented MN per state/federal standards (CCP)

Decision (NOD)

Peer-to-Peer (P2P)

Independent R

econsideration

DMHHearing

CEO Final Decision

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• State (IPRS), county & related funds • Discretionary funds, so less formal

and final decision by LME

TNO

, Term

ination, R

ADSE,

etc.

Level 1 & 2 Panels, unless Adm

inistrative

OAHMediation & Hearing

Judicial System (Courts)

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• Mix of State Law, Contracts, Waiver and URAC• About Provider paybacks, terminations, etc., not

consumer services approved or if relatives paidto give those services

Grievance lodged

Acknowledge,

assign, investigate, decide (letter)

Panel Review

CEO issues final decision

2/1/2017Due Process Overview 10

• All Staff Trained to take• Can be from (almost) Anyone, Covering (almost)

Anything • Panels: staff PLUS Consumer/Human

Rights Committee members

“There is no right to appeal the resolution of a grievance to OAH or any other forum.” NCGS §108D-12(c)

Coverage and Authorization of Services. 42 CFR 438.210

LME/MCO may place appropriate limits on services:◦ based on established criteria, medical necessity◦ for the purposes of utilization control◦ No more restrictive than DMA policy & NC State Plan

Written Policies and Procedures Consistent Application Notice Requirements (DMA standardized letters)

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Each service request must be approved or denied Consumers must receive proper notice of Denials,

including appeal (“reconsideration”) instructions• Any “managed care action,” can be appealed

Approvals must be noticed (electronically) and a service authorization issued

Upon expiration of the service authorization, a new service request must be submitted and the process starts over

Standard. Within 14 calendar days following receipt of the service request◦ Can be extended 14 additional calendar days if additional

information is required to make the decision or if consumer/provider request◦ Extension must be requested by the consumer◦ Extension must be justifiable to DMA

Expedited. Within 72 hours following receipt of the service request ◦ Required when the standard timeframe seriously

jeopardizes the consumer's life or health or ability to attain, maintain, or regain maximum function

42 CFR 438.210; URAC HUM 19-21; NCGS 108D-142/1/2017 13

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Requests include an Individual Budget (IB) The IB is used as Planning Guide—Not a Limit An algorithm is used to ensure that everyone’s

budget is fair and equitable based on others with similar needs

Individuals will be able to receive the services they need, regardless of their Individual Budget

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Supports Intensity Scale (SIS). The SIS is an important tool to assist your planning team in identifying services and supports that meet your needs, including issues with physical limitations and/or medical needs. The SIS is an interview that focuses on the support needs of a person with an intellectual and/or developmental disability.

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If you disagree with the results of the SIS assessment report, you should contact your care coordinator and notify the SIS evaluator that completes your SIS assessment. SIS Assessment results may be adjusted if it is determined that particular support needs were not accurately captured. In the event that you are not satisfied with the results of the SIS assessment or if you feel that your concerns and questions have not been addressed you have the right to file a grievance. Failure to file a grievance does not prevent you from challenging the SIS during an appeal of any managed care action.

Protections for NC Innovations Participants Care Coordinators cannot tell Participants that they cannot request

a particular service, or an amount, frequency, or duration of a service within a plan year.

Care Coordination may provide you education on the service limits. However, participants have the right to request any service, any amount of service, and any duration of service they choose.

Participants should not sign, nor should they be asked to sign, an Individual Support Plan that does not include the services they wish to request, even if the care coordinator has explained alternative service options that may be available.

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Protections for NC Innovations Participants Participants should not be asked or told that they have to sign an

Individual Support Plan that they disagree with. However, they do have to have a signed plan of care in order to receive services.

Care Coordinators will review the draft of the Individual Support Plan with participants and offer to make any requested changes before the Plan is signed. Participants should not sign a blank or incomplete Individual Support Plan. Participants should not sign an Individual Support Plan unless their Care Coordinator has reviewed it with them.

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The UM Care Manager (QP) screens all requests which are submitted by Providers or IDD Care Coordinators.

If all criteria are met, Care Managers can Approve any request for service.

If the request requires further review, it is promoted to a Clinical Care Manager (LP).

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If the Clinical Care Manager is unable to approve the request based on clinical documentation of support needs, it is referred to Peer Review

A denial or partial approval requires a Psychiatrist (MD) or Psychologist (Ph.D) Peer Reviewer to make the decision/action.

Only “managed care actions” can be appealed:o denial of a service request o limited authorization of a service requesto reduction, suspension, or termination of a previously

authorized service – i.e., changes to a current, unexpired service authorization

o Denial of payment for a service o Failure to authorize or deny a service request in a timely

mannero Failure to act within the time frames required by 42 CFR

438.408(b). 42 CFR 438.400(b); NCGS, Chapter 108D

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Action Notices include both Initial Action Notice and Reconsideration Review Decisions

Action Notices must include the information required by 42 CFR §438.404(b)

Action Notices must include the reason for the decision:◦ The Policy/Waiver language that requires the Action◦ Why the medical information submitted does not meet Policy/Waiver

criteria◦ If EPSDT applies, why the request is not medically necessary or

otherwise approvable under EPSDT◦ A link to the applicable Policy/Waiver

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The recipient’s Rights and Procedures afforded to exercise the Local Appeal process.

Innovations Only: Appeal rights are not given for adult enrollees (age 21 and older) if one service is requested above the maximum benefit limit and has been approved up to the maximum benefit set forth in the NC Innovations waiver.*

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*Adult and child beneficiaries who live in private homes withintensive support needs: These beneficiaries may receiveadditional hours of In-Home Intensive Supports or CommunityLiving and Supports to allow for 24 hours per day of support withthe prior approval of the PIHP. –Clinical Coverage Policy 8P; Att. C

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Optional part of Peer ReviewNot Reconsideration or Appeal

Interaction between Partners decision-making psychiatrist/psychology (Peer Reviewer) and lead clinician involved with the request

Opportunity to present new informationPeer Reviewer may request additional information before the conversation

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Pre-actionIn order to provide every opportunity for the ordering or

treating provider to discuss the case prior to the clinical peer reviewer completing an adverse action for prospective and concurrent requests, the peer clinical reviewer may attempt to contact the provider to discuss the case.

Post-actionThe clinical peer reviewer is available for peer to peer

conversation upon request within five working days of the action. Conversation occurs within one working day.

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Results of P2P:UnchangedReversedPartially Upheld

If this action is unchanged, yet the consumer is dissatisfied, the next step is…

Appeal means a request for review of an action (42 CFR 438.400)

Called “Reconsideration” in NC Conducted by the LME/MCO Must be decided by someone other than the individual(s) who

made the decision to take the action being appealedo Independent reviewers

“Reconsideration” of clinical actions must be decided by appropriate clinicians

Can be filed in writing or orally (oral request must be followed by a written, signed request)

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“New Evidence Rule” & Burden of Proof, NCGS 108D-15(j) &(k)

Must allow the participant a reasonable opportunity to present evidence and allegations of fact or law

Must allow the participant opportunity to examine his/her medical records and the documents considered during the appeal

The LME/MCO will never retaliate against an enrollee in any way if an enrollee chooses to appeal.

Care Coordinators can assist enrollees with the forms needed to file an appeal

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“New Evidence Rule” & Burden of Proof, NCGS 108D-15(j) &(k)

Participants can access services that were Partially Approved or Modified while appealing the service(s) that were denied

Participants may also make a new request for different services while the appeal is pending, if the Participant wishes to do so.

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Consumers must exhaust the Appeal Process (“Reconsideration”) before accessing State Fair Hearing

In North Carolina, the State Fair Hearing is called an “Appeal” and utilizes the Administrative Hearings procedure pursuant to G.S. § 150B & 108D◦ Applies to any appeal (“reconsideration”) not decided

wholly in favor of the consumer ◦ State Fair Hearing process controlled by state law and rules◦ LME/MCO is the party to the State Fair Hearing

42 CFR 438.408

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Primary NC law governing consumer appeals of LME/MCO actions

OAH does not have jurisdiction in most cases The LME/MCO is the Respondent. DMA may move to

intervene or the LME/MCO/consumer may request DMA to be a party to the hearing

OAH has 55 days from the date of the appeal to hear the case.

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Informal Telephonic Consumer, his/her representative, sometimes attorney LME/MCO clinical team Confidential Voluntary If no resolution is reached (“impasse”), appeal moves

forward Conducted by the Mediation Network of North Carolina,

although OAH will initiate and monitor process

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Conducted by an administrative law judge (ALJ) Pretrial motions, discovery, etc. Telephonic or in person hearing consumer, witnesses, and attorney LME/MCO attorney and witnesses Exhibits should be exchanged 5 days in advance Testimony, cross examination, evidence, etc. Following the hearing, the ALJ makes a decision and

forwards his/her decision to the LME/MCO and consumer

Further appeal is in Superior Court

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Maintenance of Service (MOS) does not currently apply to managed care

42 CFR 438.420 Continuation of benefits while the LME/MCO appeal and the State fair hearing are pending

Does not apply when there is no service authorization or a previously issued service authorization has expired

Applies when the LME/MCO makes changes to a current, unexpired service authorization (i.e., a reduction, suspension, or termination)

Applies during the Appeal Process (“reconsideration”) and State Fair Hearing (“appeal”).

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The LME/MCO must continue the service if all of the following are met:◦ The appeal (“reconsideration”) is timely requested◦ The appeal (“reconsideration”) involves the termination,

suspension, or reduction of a currently authorized service◦ The service was ordered by an authorized provider◦ The current service authorization has not expired◦ The consumer requests a continuation of the service

So long as all the criteria continue to be met, service continued during the Appeal Process (“reconsideration”) must also be continued during the State Fair Hearing (“appeal”)

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The service must continue until either: ◦ The consumer withdraws the appeal (“reconsideration”)◦ Ten days after the appeal (“reconsideration”) decision is made, unless

the consumer requests a State Fair Hearing within those 10 days.◦ A State Fair Hearing decision is made against the consumer◦ The service authorization expires

If the final appeal (“reconsideration”) and/or State Fair Hearing decision is against the consumer, the consumer may be responsible for the cost of the services furnished to the consumer during the appeal process (“reconsideration”) and/or State Fair Hearing. That is why consumer’s written consent required at each stage (reconsideration and appeal).

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When a provider files a Medicaid claim for services provided to a Medicaid patient, the provider shall not bill the Medicaid patient for Medicaid services for which it receives no reimbursement from Medicaid when:

(1) the provider failed to follow program regulations; (2) the agency denied the claim on the basis of a lack of medical necessity; or(3) the provider is attempting to bill the Medicaid patient beyond the situations stated in Paragraph (c) of this Rule.

10A NCAC 22J .0106

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UM Care Management ReviewPeer ReviewPeer to PeerNotices of Action

Consumer has 15 working days to file an Appeal

Partners has 7 working days to render decision

NEXT LEVEL OF APPEAL:

File a Non-Medicaid appeal request form within 11 days from the date of the notice to DMH.

DMH hearing officer will contact consumer to schedule a hearing

DMH hearing officer has 60 days from the hearing to render a recommendation.

Agency final decision by CEO rendered 10 days after recommendation received.

Can be initiated by the LME/MCO or by the consumer

Replaces the Mediation process Can resolve appeal through negotiation Informal Telephonic or In Person at the MCO

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In person, at the MCO OfficesHearing Officer Partners Witnesses and Attorneys Evidence presented by Petitioner and Respondent Recommendation by Hearing Officer in 60 days Final LME/MCO Decision by CEONo further options for Appeal

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GrievancesProvider AppealsIndividualized RatesRelative as a Direct Support

Employee (RADSE)

2/1/2017 42Enter Presentation Title

“Grievance means an expression of dissatisfaction about any matter other than an action… . The term is also used to refer to the overall system that includes grievances and appeals handled at the MCO or PIHP level and access to the State fair hearing [OAH] process. (Possible subjects for grievances 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 enrollee's rights.)” 42 CFR 438.400(b)(emphasis added).

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Review occurs by Utilization Management Additional skill level of staff Additional training so that a higher level of decision

can be made Additional supervision needed, possibly double

staffing, due to the complexity of their needs. Request forms from Provider Network Specialist

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Notice Letters Incomplete/incorrect forms will be returned to the Provider

Agency as “unable to process” “Letter of Approval” will be sent to Provider Agencies, if

Application C is approved and will document the date the decision was rendered

“Letter of Disagreement” will be sent, certified mail, to Provider Agency, if application form is not approved and will document the date the decision was rendered

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A “Letter of Disagreement” will notify a provider agency of the requirement to employ new staff or make reductions in current staff hours (if applicable) within 90 days. An Extension to the 90 day transition can be requested and extensions may be granted for up to 45 days.

“Letter of Approval” of the extension will be sent to Provider Agency, if extension has been approved, documenting the date the decision was rendered

“Letter of Disagreement” of the extension will be sent to Provider Agency, documenting the date the decision was rendered

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Questions from relatives/legal guardians regarding the RADSE Process will be address by the Provider Agency.

Relatives/legal guardians with concerns, regarding the outcome or decision of the RADSE process, should contact their Provider Agency and can also contact Partners BHM Consumer Affairs Department.

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A Provider Agency who receives a denial of their request to employ a RADSE, or a reduction in the number of hours that they can employ a RADSE, may submit a Dispute Resolution Form to the Provider Network Department

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Once the Dispute Resolution Form is received, it will be processed in accordance with the current Dispute Resolution Policy and Procedures

The Provider Dispute Resolution Form and Policy are available on Partner BHM website under Provider Information tab

For additional information, regarding RADSE please contact your Provider Network Specialist

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Charity Bridges, MA, LPA, HSP-PA◦ 704-884-2637◦ cbridges@partnersbhm.org

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