Common use of External Appeals Clause in Contracts

External Appeals. The CMS Independent Review Entity (IRE) If, on internal Appeal, the Contractor does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS If, on internal Appeal, the Contractor does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS. For standard external Appeals, the IRE will send the Enrollee and the Contractor a letter with its decision within thirty (30) calendar days after it receives the case from the Contractor, or at the end of up to a fourteen (14) calendar day extension. The CMS IRE must apply both the Medicare and MassHealth (which shall be considered supplemental services) definition for Medically Necessary Services when adjudicating the Enrollee’s Appeal for Medicare and supplemental services, and must decide based on whichever definition, or combination of definitions, provides a more favorable decision for the Enrollee. If the CMS IRE decides in the Enrollee’s favor and reverses the Contractor’s decision, the Contractor must authorize the service under dispute as expeditiously as the Enrollee’s health condition requires but no later than seventy‑two (72) hours from the date the Contractor receives the notice reversing the decision. For expedited external Appeals, the CMS IRE will send the Enrollee and the Contractor a letter with its decision within seventy‑two (72) hours after it receives the case from the Contractor, or at the end of up to a fourteen (14) calendar day extension. If the Contractor or the Enrollee disagrees with the IRE’s decision, further levels of Appeal are available, including a hearing before an Administrative Law Judge, a review by the Departmental Appeals Board, and judicial review. The Contractor must comply with any requests for information or participation from such further Appeal entities.

External Appeals. The CMS Independent Review Entity (IRE) If, on internal Appeal, the Contractor entity does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS If, on internal Appeal, the Contractor does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor entity shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS. For standard external AppealsExternal Appeals except those regarding Medicare Part B drugs, the IRE will send the Enrollee Enrollee and the Contractor entity a letter with its decision within thirty (30) calendar days (sixty (60) days for payment requests) after it receives the case from the Contractorentity, or at the end of up to a fourteen (14) calendar day extension. The CMS IRE must apply both will resolve Appeals regarding Medicare Part B drugs in accordance with the Medicare Advantage timeline for such Appeals as determined by the contract between CMS and MassHealth (which shall be considered supplemental services) definition for Medically Necessary Services when adjudicating the IRE. For all External Appeals except expedited External Appeals regarding Medicare Part B drugs, if the IRE decides in the Enrollee’s Appeal for Medicare favor and supplemental servicesreverses the entity’s decision, and the entity must decide based on whichever definition, or combination of definitions, provides a more favorable decision for authorize the service under dispute as expeditiously as the Enrollee’s health condition requires but no later than seventy-two (72) hours from the date the entity receives the Notice reversing the decision. If For expedited External Appeals, the IRE will send the Enrollee and the entity a letter with its decision within seventy-two (72) hours after it receives the case from the ICO (or at the end of up to a fourteen (14) calendar day extension). The entity will effectuate the IRE’s decision in accordance with 42 C.F.R. § 422.618(b). For expedited External Appeals regarding Medicare Part B drugs, if the CMS IRE decides in the Enrollee’s favor and reverses the Contractorentity’s decision, the Contractor must authorize the service under dispute as expeditiously as the Enrollee’s health condition requires but no later than seventy‑two twenty-four (7224) hours from the date the Contractor it receives the notice reversing the decision. For expedited external Appeals, the CMS IRE will send the Enrollee and the Contractor a letter decision in accordance with its decision within seventy‑two (72) hours after it receives the case from the Contractor, or at the end of up to a fourteen (14) calendar day extension42 CFR § 422.619(c)(2). If the Contractor entity or the Enrollee Enrollee disagrees with the IRE’s decision, further levels of Appeal are may be available, including a hearing before an Administrative Law Judge, a review by the Departmental Appeals Board, and judicial review. The Contractor entity must comply with any requests for information or participation from such further Appeal entities.. The Medicaid State Fair Hearing Process If the entity’s internal Appeal decision is not fully in the Enrollee’s favor, or if the entity fails to adhere to Notice and timing requirements the Enrollee may Appeal to MOAHR for Medicaid-based adverse decisions. Appeals to MOAHR will not be automatically forwarded by the entity. Such Appeals may be made orally, or in writing via US Mail, fax transmission, hand-delivery or electronic transmission, and in accordance with 42 C.F.R. § 431.221. An Enrollee may appoint any authorized representative, including, but not limited to, a guardian, caretaker relative, provider, friend, or legal counsel to represent the Enrollee throughout the Appeal process, in accordance with 42 C.F.R. § 435.923. The entity shall provide a form and instructions on how an Enrollee may appoint a representative. The entity shall consider the Enrollee, the Enrollee’s authorized representative, or the representative of the Enrollee’s estate as parties to the Appeal. The entity shall provide such parties a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. The entity shall allow such parties an opportunity, before and during the Appeal process, to examine the Enrollee’s case file, including medical records and any other documents and records. Appeals to the external Medicaid State Fair Hearing process filed on or after January 1, 2018 must be filed within one hundred and twenty (120) days of the Notice of resolution unless the time period is extended by MDHHS upon a finding of “good cause” in accordance with current State Fair Hearing regulations. External Appeals to the Medicaid State Fair Hearing process that qualify as Expedited Appeals shall be resolved within seventy-two (72) hours or as expeditiously as the Enrollee’s condition requires. This timeframe may be extended at the Enrollee’s request or otherwise in accordance with 42 C.F.R. § 431.244(f)(4). Hospital Discharge Appeals The ICO must comply with the hospital discharge Appeal requirements at 42 C.F.R. §§ 422.620-422.622. Other Discharge Appeals The ICO must comply with the termination of services Appeal requirements for individuals receiving services from a comprehensive outpatient rehabilitation facility, skilled nursing facilities, or home health agency at 42 C.F.R. §§ 422.624 and 422.626. Adverse Benefit Determination availability ICOs must assure Care Coordinators have access to and are informed of all Adverse Benefit Determinations including those made by First Tier, Downstream, and Related entities in order to effectively coordinate care and support beneficiaries in creating person-centered IICSPs when services are denied. Provider Appeals MDHHS Website MDHHS will update the web-site addresses of ICOs. This information will make it more convenient for providers (including out-of-network providers) to be aware of and contact respective health plans regarding documentation, prior authorization issues, and provider Appeal processes. The ICO is responsible for maintaining the prior authorization issues, and provider Appeal processes. The ICO is responsible for maintaining the completeness and accuracy of their websites regarding this information. The MDHHS web-site location is: xxx.xxxxxxxx.xxx/XXXXX. Payment Resolution Process The ICO must develop and maintain an effective provider Appeal process to promptly resolve provider billing disputes. The ICO will cooperate with providers who have exhausted the ICO’s Appeal process by entering into arbitration or other alternative dispute resolution process. Arbitration/Rapid Dispute Resolution The ICO must comply with the provisions of the Hospital Access Agreement for any non-contracted hospital providers. To resolve Claim disputes with non-contracted hospital providers, the ICO must follow the Rapid Dispute Resolution Process specified in the Medicaid Provider Manual. This applies solely to disputes with non-contracted hospital providers that have signed the Hospital Access Agreement. Non-contracted hospital providers that have not signed the Hospital Access Agreement and non-hospital providers do not have access to the Rapid Dispute Resolution Process. When a non-hospital provider or hospital provider that has not signed the Hospital Access Agreement requests arbitration, the ICO is required to participate in a binding arbitration process. Providers must exhaust the ICO’s internal provider Appeal process before requesting arbitration. MDHHS will provide a list of neutral arbitrators that can be made available to resolve billing disputes. These arbitrators will have the appropriate expertise to analyze medical Claims and supporting documentation available from medical record reviews and determine whether a Claim is complete, appropriately coded, and should or should not be paid. The party found to be liable will be assessed the cost of the arbitrator. If both parties are at fault, the cost of the arbitration will be as determined by the arbiter. Non-contracted provider Appeals. Appeals pertaining to Medicare items and services provided by non-contracted providers are governed by the rules set forth in 42 C.F.R. § 422 Subpart M and the Medicare Managed Care Manual Chapter 13. Quality Improvement Program Quality Improvement: The ICO shall deliver quality care that enables Enrollees to avoid preventable disease, manage chronic illnesses and disabilities, and maintain or improve health, food security, and quality of life, and that addresses the Social Determinants of Health to reduce Health Disparities experienced by different subpopulations of Enrollees and ultimately achieve Health Equity. Quality care refers to the following criteria: Quality of physical health care, including primary and specialty care; Quality of behavioral health care focused on recovery, resiliency and rehabilitation; Quality of LTSS; Adequate access to and availability of primary care, behavioral health care, pharmacy, specialty health care, and LTSS providers and services; Continuity and coordination of care across all care and services settings, including transitions in care; Seamless Enrollee and caregiver experience with and access to high quality, coordinated and culturally competent clinical care and services, inclusive of LTSS across the care continuum; Best practices with regards to disease and risk screening, assessment and prevention; Sufficient and capable organizational structure and staffing; Environment and actions that promote quality of life, health, and well-being for Enrollees; and Effective UM that generates value for the resources spent by Enrollees, families, and governments. Apply the principles of continuous quality improvement (CQI) to all aspects of the ICO’s service delivery system through ongoing analysis, evaluation and systematic enhancements based on: Quantitative and qualitative data collection and data-driven decision-making; Up-to-date evidence-based practice guidelines and explicit criteria developed by recognized sources or appropriately certified professionals or, where evidence-based practice guidelines do not exist, consensus of professionals in the field; Feedback provided by Enrollees and network providers in the design, planning, and implementation of its CQI activities; and Issues identified by the ICO, MDHHS and/or CMS. Ensure that the quality improvement (QI) requirements of this Contract are applied to the delivery of primary and specialty health care services, behavioral health services, and LTSS. Incorporate one or more activities that reduce disparities in health and health care. These activities must be broadly based irrespective of race, ethnicity, national origin, religion, sex, or gender. These activities may be based on health status and health needs, geography, or factors not listed in the previous sentence only as appropriate to address the relevant disparities in health and health care. QI Program Structure The ICO shall structure its QI program for the Demonstration separately from any of its existing Medicaid, or Medicare, or Commercial lines of business. For example, required measures for this Demonstration must be reported for the Demonstration population only. Integrating the Demonstration population into an existing line of business shall not be acceptable. The ICO shall maintain a well-defined QI organizational and program structure that supports the application of the principles of CQI to all aspects of the ICO’s service delivery system. The QI program must be communicated in a manner that is accessible and understandable to internal and external individuals and entities, as appropriate. The ICO’s QI organizational and program structure shall comply with all applicable provisions of 42 C.F.R. § 438, including Subpart E, Quality Assessment and Performance Improvement 42 C.F.R. § 422, Subpart D, Quality Improvement. QI Functions and responsibilities: The ICO shall establish a set of QI functions and responsibilities that are clearly defined and that are proportionate to, and adequate for, the planned number and types of QI initiatives and for the completion of QI initiatives in a competent and timely manner; Ensure that such QI functions and responsibilities are assigned to individuals with the appropriate skill set to oversee and implement an organization-wide, cross-functional commitment to, and application of, CQI to all clinical and non-clinical aspects of the ICO’s service delivery system; Seek the input of providers and medical professionals representing the composition of the ICO’s Provider Network in developing functions and activities; Establish internal processes to ensure that the QM activities for primary, specialty, and behavioral health services, and LTSS reflect utilization across the network and include all of the activities in this Section 2.13 of this Contract and, in addition, the following elements: A process to utilize Healthcare Plan Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Services (CAHPS), the Health Outcomes Survey (HOS) and other measurement results in designing QI activities

External Appeals. The CMS Independent Review Entity (IRE) If, on internal Appeal, the Contractor CICO does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor CICO shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS If, on internal Appeal, the Contractor does not decide fully in the Enrollee’s favor within the relevant time frame, the Contractor shall automatically forward the case file regarding Medicare services to the CMS IRE for a new and impartial review. The IRE is contracted by CMS. For standard external AppealsExternal Appeals except those regarding Medicare Part B drugs, the CMS IRE will send the Enrollee Enrollee and the Contractor CICO a letter with its decision within thirty (30) calendar days after it receives the case from the ContractorCICO, or at the end of up to a fourteen (14) calendar day extension, and a payment decision within sixty (60) calendar days. The CMS IRE must apply both will resolve Appeals regarding Medicare Part B drugs in accordance with the Medicare Advantage timeline for such Appeals as determined by the contract between CMS and MassHealth (which shall be considered supplemental services) definition for Medically Necessary Services when adjudicating the IRE. For all External Appeals except expedited External Appeals regarding Medicare Part B drugs, if the CMS IRE decides in the Enrollee’s Appeal for Medicare favor and supplemental servicesreverses the CICO’s decision, the CICO must authorize the service under dispute as expeditiously as the Enrollee’s health condition requires but no later than seventy-two (72) hours from the date the CICO receives the notice reversing the decision. For expedited External Appeals, the CMS IRE will send the Enrollee and the CICO a letter with its decision within seventy-two (72) hours after it receives the case from the CICO (or at the end of up to a fourteen (14) calendar day extension), a pre-service decision within thirty (30) calendar days, and must decide based on whichever definitiona payment decision within sixty (60) calendar days. The entity will effectuate the IRE’s decision in accordance with 42 C.F.R. § 422.618(b). For expedited External Appeals regarding Medicare Part B drugs, or combination of definitions, provides a more favorable decision for the Enrollee. If if the CMS IRE decides in the Enrollee’s favor and reverses the Contractor’s decision, the Contractor must authorize the service under dispute as expeditiously as the Enrollee’s health condition requires but no later than seventy‑two twenty-four (7224) hours from the date the Contractor it receives the notice reversing the decision. For expedited external Appeals, the CMS IRE will send the Enrollee and the Contractor a letter decision in accordance with its decision within seventy‑two (72) hours after it receives the case from the Contractor, or at the end of up to a fourteen (14) calendar day extension42 C.F.R. § 422.619(c)(2). If the Contractor CICO or the Enrollee Enrollee disagrees with the CMS IRE’s decision, further levels of Appeal are available, including a hearing before an Administrative Law Judge, a review by the Departmental Appeals Board, and judicial review. The Contractor CICO must comply with any requests for information or participation from such further Appeal entities. The Medicaid State Fair Hearing Process If the CICO’s internal Appeal decision is not fully in the Enrollee’s favor or the Enrollee receives a Notice of Adverse Benefit Determination related to an initial LTC LOC Assessment or initial HCBS waiver service care plan, the Enrollee may Appeal to SCDHHS Division of Appeals and Hearings for Medicaid-based adverse decisions. Appeals to the external Medicaid State Fair Hearing process will not be automatically forwarded to SCDHHS by the CICO. Such Appeals may be made via US Mail, fax transmission, telephone, hand-delivery or electronic transmission. Parties to the Medicaid Fair Hearing process include the CICO as well as the Enrollee and their representative and the representative of a deceased Enrollee’s estate. All Appeals except for those related to initial LTC LOC Assessments and initial HCBS waiver service care plans shall be registered initially with the CICO and, if the CICO’s decision is adverse to the Enrollee, the Enrollee may file an Appeal for a State Fair Hearing as provided in this Section. An Enrollee may appoint any authorized representative, including, but not limited to, a guardian, caretaker relative, or Provider, to represent the Enrollee throughout the Appeal process. The CICO shall provide a form and instructions on how an Enrollee may appoint a representative. The CICO shall consider the Enrollee, the Enrollee’s authorized representative, or the representative of the Enrollee’s estate as parties to the Appeal. The CICO shall provide such parties a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. The CICO shall allow such parties an opportunity, before and during the Appeal process, to examine the Enrollee’s case file, including medical records and any other documents and records. Appeals to the external Medicaid State Fair Hearing process must be filed within one hundred and twenty (120) calendar days of the date of the CICO ’s internal Appeal decision, unless the time period is extended by SCDHHS upon a finding of “good cause”. Appeals related to initial LTC LOC Assessments or initial HCBS waiver service care plans must be filed within one hundred and twenty (120) calendar days following the date of the notice of Adverse Benefit Determination that generates such Appeal, unless the time period is extended by SCDHHS upon a finding of “good cause”. External Appeals to the Medicaid State Fair Hearing process that qualify as Expedited Appeals shall be resolved within three (3) business days or as expeditiously as the Enrollee’s condition requires.. This timeframe may be extended at the Enrollee’s request or otherwise in accordance with 42 C.F.R. § 431.244(f)(4). External Appeals to the Medicaid State Fair Hearing process that do not qualify as expedited shall be resolved or a decision issued within ninety (90) calendar days of the date of filing the Appeal with the CICO, not including the number of days the Enrollee took to file for a State Fair Hearing. Hospital Discharge Appeals The CICO must comply with the hospital discharge Appeal requirements at 42 C.F.R. §§ 422.620-422.622. Medicare QIO Rights The CICO must comply with the termination of services Appeal requirements for Enrollees receiving services from a comprehensive outpatient rehabilitation facility, skilled nursing facilities, or home health agency, consistent with 42 C.F.R. §§422.624 and 422.626. Provider Appeals Providers should follow the CICO’s Provider Appeals process as outlined in their contract and the CICO’s Provider manual should they dispute the CICO policies, procedures, or any aspect of the CICOs administrative functions including payment, and/or UM/utilization review decision. The CICO’s Demonstration Provider Appeals system must align with the approved Medicaid Managed Care Provider Appeals system. For Appeals related to denial of payment or reduction of payment for Medicaid services, the process must provide for the following; A process to allow Providers to consolidate Appeals of multiple claims that involve the same or similar payment issues, regardless of the number of individual Enrollees or payment claims included in the bundled complaint; Provide for different levels of Appeals as follows: The CICO must investigate and render a decision regarding level one Appeals I within thirty (30) business days of the request of the Provider Appeal. To the extent the CICO upholds the decision for all or part of the amount of the dispute, the Provider may request to proceed to a level two Appeal. Such request must be made within thirty (30) days of the determination regarding the level two Appeal. The level two Appeal must consist of an administrative review conducted by a supervisor and/or manager employed by the CICO with the authority to revise the initial claims determination, if needed. A decision regarding the Appeal must be provided within thirty (30) business days of the request for the Appeal. To the extent additional information is required to render a decision on the Appeal, the CICO may extend the timeframe by fifteen (15) days based on the mutual agreement of the Provider and the CICO.