Gila River Health Care Corporation
Gila River Health Care Corporation
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 5.1 Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons

5.1.1 Introduction
5.1.2 References
5.1.3 Scope
5.1.4 Did you know…?
5.1.5 Definitions
5.1.6 Objectives
5.1.7 Procedures
5.1.7-A: General Requirements
5.1.7-B: Notice of action
5.1.7-C. Notice of action timeframes
5.1.7-D. Title XIX and Title XXI appeal and state fair hearing process
5.1.7-E: Continuation of services during the appeal or state fair hearing process

5.1.1 Introduction
All Title XIX and Title XXI eligible persons must be afforded the opportunity to appeal specified actions. The circumstances that constitute an action are defined in this section. When a provider or another entity takes certain actions as defined by this section, the Title XIX/XXI person must receive adequate and timely notice. Notice allows a Title XIX/XXI person to exercise their right to appeal a decision. Appeals of decisions for Title XIX/XXI persons not falling within the scope of this policy will be covered under Section 5.5, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).

Title XIX/XXI eligible persons who have been adversely affected by a Pre-Admission Screening and Resident Review (PASRR) determination in the context of either a preadmission screening or a resident review shall be provided notice and the opportunity to appeal.

The intent of this section is to provide information to providers that describes the Title XIX and Title XXI member appeal process and describes procedures to ensure that Title XIX/XXI persons receive appropriate notification of decisions, including:

  • The events that require notice to a Title XIX/XXI eligible person; and
  • The timeframes and content associated with providing notice.

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5.1.2 References
The following citations can serve as additional resources for this content area:

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5.1.3 Scope
To whom does this apply?

This section applies to all Title XIX and Title XXI eligible persons who are seeking covered services through the ADHS/DBHS behavioral health system.

5.1.4 Did you know?

  • ADHS/DBHS must have systems in place for Title XIX and Title XXI eligible persons that include a complaint process, an appeal process and access to the State’s Fair Hearing process.
  • All Title XIX/XXI eligible persons must receive a Notice of Action and have the right to an appeal when a claim for service relates to the payment for a service that is not Title XIX/XXI covered and the decision is to deny the claim in whole or in part. This Notice of Action must be sent to the person along with the explanation of benefits (EOB) when the claim for payment has been denied (see Section 5.6, Provider Claims Disputes).
     
  • A provider can file an appeal on behalf of a Title XIX/XXI eligible person with that person's written consent.

5.1.5 Definitions
Action

Appeal

Appeal Resolution

Complaint

Day

Denial

Health Care Professional

Limited Authorization

PASRR

Prior Authorization

Service Authorization Request

5.1.6 Objectives
The objectives of this section are to ensure that Title XIX and Title XXI eligible persons seeking or receiving covered services have access to an appeals process that fairly and efficiently resolves identified issues and that Title XIX/XXI eligible persons are provided required notices that:

  • Are timely;
  • Explain the action to be taken and the appeal process available to the person or guardian, advocate and/or designated representative; and
  • Are written in a manner that is clear and easily understood by the person.

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5.1.7 Procedures

5.1.7-A. General Requirements
Language and Format Requirements
Entities responsible for sending notice to Title XIX/XXI eligible persons must ensure that:

  • Notice and written documents related to the appeals process must be available in each prevalent, non-English language spoken within the Regional Behavioral Health Authority's (RBHA’s) geographic service area (GSA);
  • As applicable, providers must provide free oral interpretation services to explain information contained in the notice or as part of the appeal process for all non-English languages; and
  • Notice and written documents related to the appeals process must be available in alternative formats, such as Braille, large font or enhanced audio and take into consideration the special communication needs of the person; and;
  • Notice and written documents must be written using an easily understood language and format.
  • If a Title XIX/XXI member complains about the adequacy of a Notice of Action or its ability to be understood, the issuer of the Notice shall review it against the contract requirements of this policy and the AHCCCS Contractor Operations Manual (ACOM). If the issuer determines that the original Notice is inadequate or deficient, the issuer must issue an amended Notice consistent with the requirements of this policy and the ACOM. If an amended Notice is required, the timeframe for the member to appeal and request continuation of services starts from the date of the amended Notice.
  • If a member complains to the issuer regarding the adequacy of the amended Notice of Action, the issuer must promptly inform ADHS/DBHS and the AHCCCS Division of Health Care Management/Medical Management Unit (DHCM/MM) of the complaint. Additionally, the issuer must inform the member of their right to contact the AHCCCS DHCM/MM unit if the issue is not resolved to the member’s satisfaction.

Computation of time
The following methodology must be used in computing any period of time described in this section:

  • Computation of time for appeals begins the day after the act, event or decision and includes the final day of the period. For purposes of computing all timeframes with the exceptin of the standard service authorization time frames and extensions thereof; if the final day of the period is a weekend day (Saturday or Sunday) or legal holiday, the period is extended until the end of the next day that is not a weekend day (Saturday or Sunday) or a legal holiday.
  • For a standard service authorization with or without an extension, if the final day of the period is a weekend day or legal holiday the period is shortened to the last working day immediately preceding the weekend day or legal holiday. (For more information see the AHCCCS Contractor Operation Manual (ACOM) Section 414, II. Definitions).
  • Computation of time in calendar days includes all calendar days.
  • Computation of time in workdays includes all working days, i.e. non-weekend and non-holiday days.

Prohibition of punitive action
Providers must not take punitive action against a Title XIX/XXI eligible person who decides to exercise their right to appeal. RBHAs must ensure that punitive action is not taken against a provider who requests an expedited resolution to an appeal or who supports a Title XIX/XXI eligible person’s appeal.

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5.1.7-B: Notice of action
For Title XIX/XXI covered services, notice must be provided following:

  • The denial or limited authorization of a requested service, including the type or level of
    service;
  • The reduction, suspension or termination of a previously authorized service;
  • The denial, in whole or in part, of payment for a service that is not TXIX/XXI covered; and
  • The denial of the Title XIX/XXI persons' request to obtain services outside the network.

Who is responsible for sending the notice?
Following an action requiring notice to a Title XIX/XXI person, ADHS/DBHS must ensure the communication of a notice to the person.

ADHS/DBHS sends notices to Title XIX/XXI eligible persons enrolled with a Tribal RBHA (TRBHA) following:

ADHS/DBHS sends notices pursuant to Policy 1106, Pre-Admission Screening and Resident Review (PASRR) to Title XIX/XXI eligible persons who have been adversely affected by a PASRR determination in the context of either a preadmission screening or a resident review.

How is notice communicated to Title XIX/XXI eligible persons?
The use of PM Form 5.1.1 is required when providing notice regarding an action concerning a Title XIX/XXI person. (Please see the AHCCCS Contractors Operations Manual (ACOM) 414 for guidance in preparation of this form). PM Form 5.1.1 must be completed to include the following:

  • The requested service;
  • The reason/purpose of that request in layperson terms;
  • The action taken or intended to be taken (denial, limited authorization, reduction, suspension or termination) with respect to the service request;
  • The effective date of the action;
  • The reason for the action, including member specific facts and alternative services recommended, if appropriate;
  • The legal basis for the action;
    • General citations are not sufficient; an explanation must be provided in easily understood language
  • Where members can find copies of the legal basis;
    • When a legal authority, including an internal policy manual, is available online, the Notice shall state the accurate website link to enable the member to find the legal authority online
  • The right to and process for appealing the decision; and
  • Legal resources for members for help with appeals, as prescribed by the Arizona Health Care Cost Containment System (AHCCCS) (See AHCCCS Contractors Operations Manual (ACOM) 414, Attachment B).

Notices of Action must cite AHCCCS Early Periodic Screening, Diagnosis and Treatment (EPSDT) Rule A.A.C. R9-22-213 and federal law 42 USC 1396d(r)(5) when denying, reducing or terminating a service for a Title XIX member who is younger than 21 years of age when these provisions are applicable. When the T/RBHA or the T/RBHA provider denies, reduces, or terminates services that have been requested for Title XIX members under the age of 21, the T/RBHA or the T/RBHA provider must explain why the requested services do not meet the conditions as described in this Policy and the AHCCCS Medical Policy Manual (AMPM) Chapter 400, Policy 430. The T/RBHA or the T/RBHA provider must specify why the requested services do not meet the EPSDT criteria and are not covered and must also specify that EPSDT services include coverage of screening services, vision services, dental services, hearing services and such other necessary health care, diagnostic services, treatment and other measures described in federal law subsection 42 USC 1396(d)(a) to correct or ameliorate (make better) defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the AHCCCS State Plan.

Delivery of Notices
The Notice of Action must be delivered to the Title XIX/XXI eligible person and, when applicable, their legal or authorized representative (e.g., Arizona Department of Economic Security/Arizona Department of Child Safety (DES/DCS) Specialist and/or advocate for SMI persons requiring special assistance). For Title XIX/XXI eligible persons under the age of 18, the Notice of Action must be delivered to their legal or custodial parent or a government agency with legal custody of the Title XIX/XXI eligible person.

All notices must be personally delivered or mailed by certified mail to all parties at their last known residence or place of business. In the event that it may be unsafe to contact a person at his or her home address, or the person does not want to receive mail at home, alternate methods identified by the person for communicating notice must be used.

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5.1.7-C. Notice of action timeframes
For service authorization requests, the following timeframes for sending notice of action are in effect (see Section 3.14, Securing Services and Prior Authorization for required timeframes for decisions regarding prior authorization requests):

  • For an authorization decision related to a service requested by or on behalf of a Title XIX/XXI eligible person, the responsible entity must send a notice of action within 14 calendar days following the receipt of the behavioral health recipient’s request;
  • For an authorization request in which the provider indicates, or the responsible entity determines, that the 14 calendar day timeframe could seriously jeopardize the person's life or health or ability to attain, maintain or regain maximum function, the responsible entity must make an expedited authorization decision and send the Notice of Action as expeditiously as the person’s health condition requires, but no later than three working days after receipt of the request for service;
  • If ADHS/DBHS, a T/RBHA or a T/RBHA provider receives a request for an expedited service authorization decision, and the requested service is not of an urgent medical nature, the expedited request may be downgraded to a standard request. ADHS/DBHS, the T/RBHA and/or T/RBHA provider must have a process, included in its policy for prior authorization, which describes how the requesting provider will be notified of the downgrade and given an opportunity to disagree. The requesting provider must be allowed to send additional documentation supporting the need for an expedited authorization.
  • If the Title XXI/XIX eligible person requests an extension of either timeframe above, the responsible entity must extend the timeframe up to an additional 14 days;
  • If the responsible entity needs additional information and the extension is in the best interest of the person, the responsible entity shall extend the 14 calendar day or the three working day timeframe up to an additional 14 days. If the responsible entity extends the timeframe, the responsible entity must:
  • For service authorization decisions not reached within the maximum timeframes outlined above, the authorization shall be considered denied on the date that the timeframe expires.
  • ADHS/DBHS, the Tribal/Regional Behavioral Health Authority (T/RBHA) or T/RBHA provider shall provide the requesting provider notification of a decision to deny a service authorization. The notification must be in writing.

For service terminations, suspensions or reductions, the following timeframes are in effect:

  • The responsible entity must send the Notice of Action at least 10 days before the date of the action with the following exceptions:
    • The responsible entity may send the Notice of Action no later than the date of the action if:
      • The responsible entity has factual information confirming the death of a Title XIX/XXI person;
      • The responsible entity receives a clear written statement signed by the Title XIX/XXI person that the person no longer wants services or gives information to the responsible entity that requires termination or reduction of services and indicates that the person understands that this will be the result of supplying that information;
      • The Title XIX/XXI person is an inmate of a public institution that does not receive federal financial participation and the person becomes ineligible for TXIX/XXI;
      • The Title XIX/XXI person’s whereabouts are unknown and the post office returns mail to the responsible entity indicating no forwarding address;
      • The responsible entity establishes the fact that the Title XIX/XXI person has been accepted for Medicaid by another state; or
      • A change in the level of medical care is prescribed by the member's physician.
    • The responsible entity may shorten the period of advance notice to five days before the date of action if the responsible entity has verified facts indicating probable fraud waste or program abuse by the Title XIX/XXI eligible person.
    • The responsible entity may shorten the period of advance notice to two (2) working days before the date of the action for the termination of non-emergency inpatient services, as a result of a denial of a continued stay request.

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5.1.7-D. Title XIX and Title XXI appeal and state fair hearing process
Who is responsible?
Each RBHA is responsible for processing appeals and may not delegate this function to a provider. ADHS/DBHS processes appeals related to actions initiated by a Tribal RBHA or one of their subcontracted providers. Any responsibilities attributed to a RBHA in Subsections 5.1.7-D and 5.1.7-E of this section are the responsibility of ADHS/DBHS if the action relates to a Tribal RBHA or one of their subcontracted providers, or relates to an appeal concerning a PASRR determination.

The following information is provided to familiarize providers with the Title XIX/XXI appeal process.

Who can file an appeal or request a State Fair Hearing?
The following persons or representatives may file an appeal or request a State Fair Hearing regarding an action:

  • A Title XIX/XXI eligible person;
  • A legal or authorized representative (e.g., Department of Economic Security/Division of Children, Youth and Families/Child Protective Services Specialist and/or advocate for SMI persons requiring special assistance), including a provider, acting on behalf of the person, with the person’s written consent;
  • A Title XIX/XXI eligible person adversely affected by a PASRR determination in the context of either a preadmission screening or a resident review.

What is the timeframe for filing an appeal?
A Title XIX/XXI eligible person has up to 60 days after the date of the Notice of Action to file a standard appeal. The appeal may be filed orally or in writing.

How long does the RBHA have to resolve a standard appeal?
The RBHA must resolve standard appeals no later than 30 days from the date of receipt of the appeal, unless an extension is in effect.

Can the standard appeal resolution timeframe be extended?
If a Title XIX/XXI eligible person requests an extension of the 30-day timeframe, the RBHA must extend the timeframe up to an additional 14 days. If the RBHA needs additional information and the extension is in the best interest of the person, the RBHA may extend the 30-day timeframe up to an additional 14 days.

Under what circumstances must an appeal be expedited?
The RBHA can conduct an expedited appeal if:

  • The RBHA receives a request for an appeal from a Title XIX/XXI eligible person and the RBHA determines that taking the time for a standard appeal resolution could seriously jeopardize the person’s life or health, or ability to attain, maintain, or regain maximum function;
  • The RBHA receives a request for an expedited appeal from a Title XIX/XXI eligible person supported with documentation from the provider that taking the time for a standard resolution could seriously jeopardize the person’s life or health, or ability to attain, maintain or regain maximum function; or
  • The RBHA receives a request for an expedited appeal directly from a provider, with the Title XIX/XXI eligible person’s written consent, and the provider indicates that taking the time for a standard resolution could seriously jeopardize the person’s life or health, or ability to attain, maintain or regain maximum function.


What if the request for an expedited appeal is denied?

If the RBHA denies a request for expedited resolution of an appeal from a Title XIX/XXI eligible person, the RBHA must resolve the appeal within the standard resolution timeframe and make reasonable efforts to give the person prompt oral notice of the denial. Within two calendar days, the RBHA must follow up with written notice of the denial.

How long does the RBHA have to resolve an expedited appeal?
The RBHA must resolve expedited appeals within three working days after the day the RBHA receives the appeal.

Can the expedited appeal resolution timeframe be extended?
If a Title XIX/XXI eligible person requests an extension of the three working day timeframe, the RBHA must extend the timeframe up to an additional 14 days. If the RBHA needs additional information and the extension is in the best interest of the person, the RBHA must extend the three working day timeframe up to an additional 14 days.

Requesting a State Fair Hearing
A Title XIX/XXI eligible person, legal or authorized representative may request a State Fair Hearing on the RBHA’s resolution of an appeal. The request must be in writing and submitted to ADHS/DBHS. The request must be received by ADHS/DBHS no later than 30 days after the date that the person received the Notice of the Appeal Resolution.

What assistance must be provided to Title XIX/XXI eligible persons in filing an appeal and/or requesting a State Fair Hearing?
Reasonable assistance must be provided to Title XIX/XXI eligible persons in completing forms and other procedural steps. Reasonable assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD (teletypewriter/telecommunications device for the deaf and text telephone) and interpreter capability. Reasonable assistance may be offered by a provider or referred to the RBHA or, for Title XIX/XXI eligible persons enrolled with a Tribal RBHA, by contacting ADHS/DBHS Office of Grievance and Appeals at (602) 364-4575.

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5.1.7-E: Continuation of services during the appeal or state fair hearing process
For the purposes of this subsection, if the following criteria are met, services shall be continued based on the authorization that was in place prior to the denial, termination, reduction or suspension of services that has been appealed. A Title XIX/XXI eligible person’s services can continue during the appeal and State Fair Hearing process, unless continuation of services would jeopardize the health or safety of the person or another person, if:

  • The person files the appeal timely*;
  • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment or the appeal involves a denial if the provider asserts the denial represents a necessary continuation of a previously authorized service;
  • The services were ordered by an authorized provider; and
  • The person requests continuation of services.

*Timely filing means filing on or before the later of the following:

  • Within 10 days after the date that the RBHA mails or delivers the Notice of Action; or
  • The effective date of the action as indicated in the Notice of Action.

If a person wishes services to continue during appeal they must request the continuation of services when the appeal is initially filed and at the time of requesting a State Fair Hearing.

At what point will a person’s services no longer be continued during the appeal or State Fair Hearing process?
The RBHA must continue services until one of the following occurs:

  • The Title XIX/XXI eligible person withdraws the appeal;
  • The Title XIX/XXI eligible person makes no request for continued benefits within 10 days of the delivery of the Notice of Appeal Resolution; or
  • The AHCCCS Administration issues a State Fair Hearing decision adverse to the Title XIX/XXI person.

What happens if the person loses the appeal?
If the Director’s decision upholds the RBHA’s action, the RBHA may recover the cost of the services furnished to a Title XIX/XXI eligible person while the appeal is pending if the services were furnished solely because of the requirements of subsection 5.1.7-E.

What happens if a decision to deny authorization of services is reversed by ADHS/DBHS?
If the RBHA or AHCCCS Director's Decision reverses a decision to deny, limit, or delay authorization of services, and the member received the disputed services while an appeal was pending, the RBHA shall process a claim for payment from the provider in a manner consistent with the RBHA’s or Director's Decision and applicable statutes, rules, policies, and contract terms. (See ARS 36-2904)

The provider shall have 90 days from the date of the reversed decision to submit a clean claim to the RBHA for payment. For all claims submitted as a result of a reversed decision, the RBHA is prohibited from denying claims as untimely if they are submitted within the 90-day timeframe.

RBHAs are also prohibited from denying claims submitted by Providers as a result of a reversed decision because the member chooses not to request continuation of services during the appeals/hearing process: a member’s failure to request continuation of services during the appeals/hearing process is not a valid basis to deny the claim.

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5.1 Title XIX/XXI Notice/Appeal Requirements
Last Revised: 10/1/2014
Effective Date: 10/1/2014

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