Library: Policy

317:2-3-10. Provider complaint system and appeal requests

Revised 7-1-23

(a) A participating provider or nonparticipating provider may file a complaint whenever:

(1) The provider is not satisfied with the CE's or DBM's policies and procedures; or

(2) The provider is not satisfied with a decision made by the CE and DBM that does not impact the provision of services to members.

(b) The CE and DBM will establish and operate a provider complaint system. Such system will:

(1) Use written policies and procedures for receiving, tracking, dating, storing, responding to, reviewing, reporting, and resolving provider complaints;

(2) Track receipt and resolution of provider complaints, including requests for reconsideration or appeals;

(3) Demonstrate sufficient ability to receive provider complaints by telephone, in writing, or in person;

(4) Designate staff to receive, process, and resolve provider complaints;

(5) Thoroughly investigate each provider complaint;

(6) Ensure an escalation process for provider complaints;

(7) Furnish the provider timely written notification of resolution or results; and

(8) Maintain a tracking system capable of generating reports to OHCA on provider complaint volume and resolution.

(c) The CE and DBM will operate a reconsideration process whereby providers may request the CE and DBM reconsider a decision the CE and DBM has made or intends to make that is adverse to the provider, including, at minimum, reconsiderations of provider audit findings, reconsiderations of provider agreement termination, and reconsiderations of denied claims.

(1) Request for reconsideration, denied claims. The CE and DBM will ask that the provider submits a request for reconsideration of a denied claim within six (6) months after the provider receives notice of the denied claim.

(2) Request for reconsideration, all other reasons. The CE and DBM will ask that the provider submits a request for reconsideration within fifteen (15) days after the date the provider receives notice of audit findings, termination of provider agreement, or other actions the CE and DBM permits for reconsideration requests.

(3) Desk review. The CE and DBM will conduct the reconsideration through a desk review of the request and all related and available documents.

(4) Reconsideration resolution. The CE and DBM will resolve all requests for reconsideration within the timeframes established by the OHCA. The CE and DBM will send a reconsideration resolution notice to the provider within five (5) calendar days of resolution of the consideration.

(5) Notice of reconsideration resolution. The CE and DBM will send a reconsideration resolution notice that contains, at a minimum:

(A) The date of the notice;

(B) The action the CE has made or intends to make;

(D) The date the action was made or will be made;

(E) The citation to statute, regulation, policy, or procedure, if any, upon which the action was based;

(F) An explanation of the provider's ability to submit an appeal request to the CE and DBM within thirty (30) calendar days of the date recorded on the notice;

(G) The address and contact information for submitting an appeal;

(H) The procedures by which the provider may request an appeal regarding the CE's or DBM's action;

(I) The specific change in federal or state law, if any, that requires the action;

(J) The provider's ability to submit a state fair hearing request following completion of the provider appeal process, or, in cases of an action based on a change in law, the circumstances under which a state fair hearing will be granted; and

(K) Any other information required by state or federal statute or regulation, by contract, or by contract-related manual.

(d) The CE and DBM will operate an appeals process whereby a provider may request an appeal of a reconsideration resolution when the underlying matter is based on the CE or DBM's provider audit findings or for-cause or immediate termination of the provider agreement.

(1) Request for appeal. The CE and DBM will require the provider to submit a request for appeal in writing within thirty (30) calendar days after the provider receives notice reconsideration resolution.

(2) Panel review. The CE and DBM will conduct the appeal through a panel review including a hearing and review of the request, all related and available documents, and all documents created for or used in connection with the request for reconsideration.

(A) The panel will consist of three (3) or five (5) reviewers, who are employees or officers of the CE and DBM.

(B) Panel members will not have been directly involved with the reconsideration desk review and will not be a subordinate of someone involved directly with the reconsideration desk review.

(C) The panel review hearing will provide the provider or an authorized representative of the provider with a reasonable opportunity to be heard in person or by telecommunications.

(D) The review panel will accept and document any exhibit offered prior to the hearing or during the hearing, so long as the exhibit directly relates to the matter of the appeal.

(E) When the appeal is based on a claim denied on the basis of medical necessity, the following requirements apply:

(i) Medical or dental review staff of the CE and DBM will be licensed or credentialed health care clinicians with relevant clinical training or experience; and

(ii) All CEs or DBMs will use medical or dental review staff for such appeals and will not use any automated claim review software or other automated functionality for such appeals.

(3) Appeal resolution. The CE and DBM will resolve all appeals within the timeframes established by the OHCA. The CE and DBM will send an appeal resolution notice to the provider within five (5) calendar days of the CE and DBM finalizing the resolution.

(4) Notice of appeal resolution. The CE and DBM will send an appeal resolution notice that contains, at a minimum:

(A) The date of the notice;

(B) The date of the appeal resolution; and

(i) An explanation of the provider's ability to request and OHCA administrative appeal within thirty (30) calendar days of the date recorded on the notice;

(ii) How to request an OHCA administrative appeal, including the OHCA address and contact information for submitting a request;

(iii) Details on the right to be represented by counsel at the OHCA administrative appeal.

(D) Any other information required by state or federal statute or regulation, by Contract, or by Contract-related manual.

(5) Documentation. The CE and DBM will furnish to OHCA documentation including all information specified within the Contract within fifteen (15) calendar days of a provider's request for an OHCA administrative appeal.

(6) State fair hearing for providers. There are no state fair hearings provided for providers under a CE or DBM, per OAC 317:2-3-13.