La. Admin. Code tit. 50 § XXXIII-701

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXXIII-701 - General Provisions

A. The MCOs and the CSoC contractor shall be required to have an internal grievance system and internal appeal process. The appeal process allows a Medicaid recipient/enrollee to challenge a decision made, a denial of coverage, or a denial of payment for services.

B. An enrollee, an enrollees authorized representative or a provider on behalf of an enrollee, with the enrollees prior written consent, has 60 calendar days from the date on the notice of action in which to file an appeal.

C. An enrollee, an enrollees authorized representative or a provider on behalf of an enrollee, with the enrollees prior written consent, may file a grievance at any time after an occurrence or incident which is the basis for the grievance.

D. An enrollee must exhaust the MCO or the CSoC contractor grievance and appeal process before requesting a state fair hearing.

E. The MCO and CSoC contractor shall provide Medicaid enrollees with information about the state fair hearing process within the timeframes established by the department and in accordance with the state fair hearing policies.

La. Admin. Code tit. 50, § XXXIII-701

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:363 (February 2012), Amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 412356 (11/1/2015), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43322(2/1/2017), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 441890 (10/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.