- A. A contractor shall provide reasonable assistance to enrollees in completing forms and taking 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.
- B. The contractor shall acknowledge receipt of each grievance orally or in writing. The contractor shall acknowledge receipt of each appeal in writing.
- C. The contractor shall ensure that the individual who makes a decision on a grievance or an appeal was not involved in any previous level of review or decision-making.
D. The contractor shall ensure that a health care professional who makes decisions on any of the following appeals or grievances has the appropriate clinical expertise in treating the enrollee’s condition or disease:
- 1. An appeal of a denial that is based on lack of medical necessity,
- 2. A grievance regarding denial of expedited resolution of an appeal, or
- 3. A grievance or appeal that involves clinical issues.
Historical Note
New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).