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Library: Policy

317:35-18-7. Programs of All-Inclusive for the Elderly (PACE) organization's appeals process

Revised 9-1-21

(a) Internal appeals:

(1) Any individual who is denied program services is entitled to an appeal through the provider.

(2) If the individual also chooses to file an external appeal, the provider must assist the individual in filing an external appeal.

(b) External appeals may be filed through the OHCA legal division and follow the process outlined in Oklahoma Administrative Code (OAC) 317:2-1-2.

(c) Expedited appeals process (refer to 42 CFR ' 460.122).

(1) A PACE organization must have an expedited appeals process for situations in which the participant believes that his or her life, health, or ability to regain or maintain maximum function could be seriously jeopardized, absent provision of the service in dispute.

(2) Except as provided in paragraph (c)(3) of this section, the PACE organization must respond to the appeal as expeditiously as the participant's health condition requires, but no later than seventy-two (72) hours after it receives the appeal.

(3) The PACE organization may extend the seventy-two (72) hour timeframe by up to fourteen (14) calendar days for either of the following reasons:

(A) The participant requests the extension; or

(B) The organization justifies to the State administering agency (OHCA) the need for additional information and how the delay is in the interest of the participant.

(4) Supporting documentation must be submitted to (OHCA) once it has been determined that they will be unable to respond to the appeal within the seventy-two (72) hour timeframe.