1. Adverse Benefit Determination—any of the following:

   1. 1. the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
   2. 2. the reduction, suspension, or termination of a previously authorized service;
   3. 3. the denial, in whole or in part, of payment for a service;
   4. 4. the failure to provide services in a timely manner, as defined by the state;
   5. 5. the failure of an MCO to act within the timeframes provided in 42 CFR §438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals;
   6. 6. the denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductible, coinsurance, and other member financial liabilities.
2. Appeal—a request for review of an adverse benefit determination as defined in this Section.

3. Grievance—an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to:

   1. 1. the quality of care or services provided;
   2. 2. aspects of interpersonal relationships, such as rudeness of a provider or employee;
   3. 3. failure to respect the member’s rights regardless of whether remedial action is requested; or
   4. 4. the member’s rights to dispute an extension of time proposed by the MCO to make an authorization decision.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:1589 (June 2011), amended LR 41:939 (May 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 44:285 (February 2018).