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

3 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

4 Grievance System. 42 CFR 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 2/1/2017 4

Robust and Multi-Door Four Dispute Types: Consumer: any entitlement belongs to consumer 1. Medicaid Appeals: Medicaid services denied, terminated, suspended or reduced 2.

5 Robust and Multi-Door Four Dispute Types: Consumer: any entitlement belongs to consumer 1. Medicaid Appeals: Medicaid services denied, terminated, suspended or reduced 2. Non-Medicaid Appeals: consumer services funded by state, county and other sources 3. Provider Disputes: TNOs, terminations, RADSE any entitlement belongs to provider 4. Grievances (anyone): most any other complaint or dispute Due Process Overview 2/1/2017 5

6 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 ; URAC HUM 38 &39; NCGS, Chapt. 108D 2/1/2017 6

7 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 or NOA) Peer-to- Peer (P2P) Independent Reconsideration OAH & Mediation Judicial System (Courts) Due Process Overview 2/1/2017 7

8 State (IPRS), county & related funds Discretionary funds, so less formal and final decision by LME Decision (NOD) Peer-to- Peer (P2P) Independent Reconsideration DMH Hearing CEO Final Decision Due Process Overview 2/1/2017 8

9 Mix of State Law, Contracts, Waiver and URAC About Provider paybacks, terminations, etc., not consumer services approved or if relatives paid to give those services TNO, Termination, RADSE, etc. Level 1 & 2 Panels, unless Administrative OAH Mediation & Hearing Judicial System (Courts) Due Process Overview 2/1/2017 9

10 All Staff Trained to take Can be from (almost) Anyone, Covering (almost) Anything Panels: staff PLUS Consumer/Human Rights Committee members Grievance lodged Acknowledge, assign, investigate, decide (letter) Panel Review CEO issues final decision There is no right to appeal the resolution of a grievance to OAH or any other forum. NCGS 108D-12(c) Due Process Overview 2/1/

Coverage and Authorization of Services. 42 CFR 438.

11 Coverage and Authorization of Services. 42 CFR 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) 2/1/

12 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 2/1/

13 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 ; URAC HUM 19-21; NCGS 108D-14 2/1/

14 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 2/1/

15 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. 2/1/

16 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. 2/1/

17 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. 2/1/

18 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. 2/1/

19 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). 19

20 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. 20

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

21 Only managed care actions can be appealed: o denial of a service request o limited authorization of a service request o 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 manner o Failure to act within the time frames required by 42 CFR (b). 42 CFR (b); NCGS, Chapter 108D 2/1/

22 Action Notices include both Initial Action Notice and Reconsideration Review Decisions Action Notices must include the information required by 42 CFR (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 2/1/

23 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.* *Adult and child beneficiaries who live in private homes with intensive support needs: These beneficiaries may receive additional hours of In-Home Intensive Supports or Community Living and Supports to allow for 24 hours per day of support with the prior approval of the PIHP. Clinical Coverage Policy 8P; Att. C 23

24 Optional part of Peer Review Not Reconsideration or Appeal Interaction between Partners decision-making psychiatrist/psychology (Peer Reviewer) and lead clinician involved with the request Opportunity to present new information Peer Reviewer may request additional information before the conversation 24

25 Pre-action In 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-action The 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. 25

26 Results of P2P: Unchanged Reversed Partially Upheld If this action is unchanged, yet the consumer is dissatisfied, the next step is 26

27 Appeal means a request for review of an action (42 CFR ) 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 appealed o 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) New Evidence Rule & Burden of Proof, NCGS 108D-15(j) &(k) 2/1/

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

28 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 New Evidence Rule & Burden of Proof, NCGS 108D-15(j) &(k) 2/1/

29 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. 2/1/

30 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 /1/

31 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. 2/1/

32 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 2/1/

33 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 2/1/

34 Maintenance of Service (MOS) does not currently apply to managed care 42 CFR 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 ). 2/1/

35 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 ) 2/1/

36 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). 2/1/

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

37 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 /1/

38 UM Care Management Review Peer Review Peer to Peer Notices of Action

39 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.

40 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 2/1/

41 In person, at the MCO Offices Hearing Officer Partners Witnesses and Attorneys Evidence presented by Petitioner and Respondent Recommendation by Hearing Officer in 60 days Final LME/MCO Decision by CEO No further options for Appeal 2/1/

42 Grievances Provider Appeals Individualized Rates Relative as a Direct Support Employee (RADSE) Enter Presentation Title 2/1/

43 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 (b)(emphasis added). 2/1/

44 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 2/1/

45 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 2/1/

46 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 2/1/

47 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. 2/1/

48 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 2/1/

49 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 2/1/

50 2/1/

51 Charity Bridges, MA, LPA, HSP-PA /1/

The Basics of LME/MCO Authorization and Appeals

The Basics of LME/MCO Authorization and Appeals Tracy Hayes, JD General Counsel and Chief Compliance Officer July 17, 2014 DSS Attorneys Summer Conference Asheville, NC What is Smoky Mountain? Area Authority