Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 11 - Informal Grievances and Appeals

Definitions

  • Grievances are defined, as complaints not related to a specific action.
  • An action as applicable to the PRIME program, is defined as the denial of a service, or the limitation, reduction, suspension, or termination of a previously authorized service including the type or level of services. An action does not include those decisions of a provider exercising his or her professional judgment.
  • Appeals are defined as complaints related to specific actions taken by either the State or PCPs that result in denial of payment or services.
  • Expedited appeal where the State determines that delays under the standard time frame could jeopardized the individual’s life or health.

Time Frames

  • Recipients have the right to file an appeal within 30 days of notification of the adverse action.
  • Recipients have the right to a decision within 90 days after filing a grievance or appeal unless “expedited” status is determined.
  • Expedited appeals must be resolved within 72 hours after the recipient provides the required supporting documentation.

Process

Appeals may be accepted verbally but must be followed by filing a written, signed, appeal unless “expedited” status is determined. Grievances may be accepted and resolved verbally or written. The State will make its determination through an informal investigation utilizing one or more but not limited to the following procedures:

  • Mediation
  • Documentation and record review
  • Other

Recipients who have grievances/appeals that can not be resolved through the informal process will be informed of the formal appeals process (Fair Hearing).