Library: Policy

317:2-3-5. Member appeals

Revised 7-1-23

(a) Filing.

(1) Filing with a CE or DBM. Except as described in this Section, when the member is enrolled in a managed care program, the member initially files an appeal with the CE or DBM in which the member is enrolled.

(2) Exception: Filing with OHCA. When the member is enrolled in a SoonerSelect program, the member initially files administrative appeals with OHCA and follows the appeals rules set forth at OAC 317:2-1-2 et seq. whenever the appeal concerns a decision the OHCA made regarding:

(A) Eligibility for Oklahoma Medicaid;

(B) Eligibility for a SoonerSelect program;

(D) Enrollment, including use of an auto-assignment algorithm, into a CE or DBM;

(E) Disenrollment from a CE or DBM; or

(F) Any other matter, so long as OHCA made the decision in the matter.

(b) Timing.

(1) Per OAC 317:2-3-4(b), a member may file a grievance at any time. If the grievance decision is adverse to the member, the member may file an appeal. The member has sixty (60) days from the adverse decision notice to file an appeal.

(2) An administrative appeal or state fair hearing request made to OHCA shall conform with the requirements of OAC 317:2-1-2 et seq. in terms of the manner and timing of any such filing.

(d) Provider's and authorized representative's right to file an appeal. A provider or an authorized representative may file an appeal on behalf of a member, provided that the provider or authorized representative has obtained the member's written consent to do so. The authorized representative of a deceased member's estate may also be a party to the litigation of an appeal, as applicable.

(e) Clinical expertise in an appeal decision. When an appeal involves clinical issues or is related to a denial based on lack of medical necessity, the decision maker(s) of such an appeal will have clinical expertise as discussed at OAC 317:2-3-6.

(f) Consideration of information in an appeal decision. The decision maker(s) for any appeal will take into account all comments, documents, records, and other information submitted without regard to whether such information was submitted or considered in the initial determination.

(g) OHCA-established timeframes for appeals decisions. An appeal related in any way to the member's health condition will be resolved, with notice provided, as expeditiously as the member's health condition requires.

(1) Per 42 C.F.R. § 438.408, the OHCA establishes the following timeframes for appeals:

(A) Standard resolution of an appeal will occur within thirty (30) calendar days, excluding any extensions, after the CE or DBM receives the appeal;

(B) The CE and DBM will be responsible for expedited resolutions.

(i) An expedited appeal resolution should occur if the standard resolution timeframe could jeopardize the Enrollee's life or health or ability to attain, maintain, or regain maximum function.

(ii) Per 42 C.F.R. § 438.408(b)(2), if the CE or DBM denies a request for expedited appeal resolution, the CE or DBM must transfer the appeal to the standard appeal resolution timeframe.

(C) In exigent circumstances, resolution of a step therapy request appeal will occur within twenty-four (24) clock-hours after the CE receives the appeal; and

(D) In all other circumstances, resolution of a step therapy request appeal will occur within seventy-two (72) clock-hours after the CE receives the appeal.

(2) The CE and DBM may extend the timeframes in (g)(1)(A) or (B) up to fourteen (14) days if:

(A) The member requests the extension; or

(B) The CE and DBM shows (to the OHCA's satisfaction upon OHCA's request) that there is need for additional information and how the delay is in the member's interest.

(3) If the CE and DBM extends the timeframes not at the request of the member, it must complete all of the following:

(A) Make reasonable efforts to give the member prompt oral notice of the delay;

(B) Within two (2) calendar days give the member written notice of the reason for the decision to extend the timeframe and inform Enrollee of the right to file a grievance if he or she disagrees with that decision; and

(C) Resolve the appeal as expeditiously as the member's health condition requires and no later than the date the extension expires.

(4) The CE and DBM will adhere to all OHCA policies related to appeals, including but not limited to:

(A) Observing the timeframes for resolving appeals, including standard resolution, expedited resolution, and resolution of step therapy appeals (in both exigent and other circumstances);

(B) Sending acknowledgement of receiving the appeal in writing to the member or the member's authorized representative within five (5) calendar days of receipt;

(C) Sending written notice conforming with this Subchapter to the affected parties within three (3) calendar days following resolution of the appeal; and

(D) Sending documentation, in conformance with OAC 317:2-3-12(d) and any established OHCA forms or processes, to OHCA within fifteen (15) calendar days after a request for state fair hearing.