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Washington MMC Appeals

Appeals Process

An enrollee, the enrollee’s authorized representative, or a provider acting on behalf of the enrollee and with the enrollee’s written consent, may appeal a MCO adverse benefit determination.

If a provider has requested an appeal on behalf of an enrollee, but without the enrollee’s written consent, the MCO shall not dismiss the appeal without first contacting the enrollee within five (5) calendar days of receipt of the provider’s request, informing the enrollee that an appeal has been made on the enrollee’s behalf, and then asking the enrollee if they would like to continue the appeal.  The MCO shall have made at least three different attempt to contact the enrollee on three different business days, at three different times during the day, without success, prior to dismissing the provider-initiated appeal request.

For appeals of standard service authorization decisions, an enrollee, or provider acting on behalf on the enrollee, must file an appeal, either orally, or in writing within sixty (60) calendar days of the date on the MCO’s Notice of Adverse Benefit Determination. 

For appeals for termination, suspension, or reduction of previously authorized services when the enrollee requests continuation of such services, an enrollee must file an appeal within ten (10) calendar days of the date of the MCO’s mailing of the Notice of Adverse Benefit Determination.  If the enrollee is notified in a timely manner and the enrollee’s request for continuation of services is not timely, the MCO is not obligated to continue services and the timeframes for appeals of standard resolution apply.

For standard resolution of appeals and for appeals for termination, suspension or reduction of previously authorized services a decision mist be made within fourteen (14) calendar days after the receipt of the appeal, unless the MCO notifies the enrollee that an extension is necessary to complete the appeal; however, the extension cannot delay the decision beyond twenty-eight (28) calendar days of the request for appeal.  For any extension not requested by an enrollee, the MCO shall resolve the appeal as expeditiously as the enrollee’s health condition requires and no later than the date the extension expires.

The enrollee may request an extension in the timeframe for processing an appeal for up to fourteen (14) calendar days.  For any extension not requested by an enrollee, the MCO must document how the delay is in the enrollee’s best interest.

Continuation of Benefits

Termination, suspension, or reduction of previously authorized services: The authorization decision and notice is provided ten (10) calendar days prior to such termination, suspension, or reduction, except in the following circumstances:

    • The enrollee dies;
    • The contractor has signed a written Enrollee statement requesting service termination or giving information requiring termination, reduction, or suspension of services is the result of supplying this information;
    • The enrollee is admitted to an institution where she is ineligible for services;
    • The enrollee’s address is unknown and mail directed to her has no forwarding address;
    • The enrollee has moved out of the contractor’s service area past the end of the month for which the premium has been paid;
    • The enrollee’s PCP prescribes the change in the level of care; or
    • An adverse determination regarding the preadmission screening for nursing facility was made.

Expedited Appeal Process

The enrollee may file an expedited appeal either orally or in writing.  No additional enrollee follow-up is needed. 

For expeditated resolution of appeals authorization decisions, including notice to affected parties, the MCO shall make the decision within seventy-two (72) hours after the MCO receives the appeal.

The enrollee may request an extension in the timeframe for processing an appeal for up to fourteen (14) calendar days.  For an extension not requested by an enrollee. The MCO must document how the delay is in the best interest of the enrollee and make reasonable efforts to provide oral notice of delay.  The MCO must follow up with a written notice after two (2) calendar days.

If the MCO denies a request for expediated resolution of an appeal, it shall transfer the appeal to the standard resolution of the appeals timeframe; and make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two (2) calendar days with a written notice of denial.

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