1. A. The MCOs and the CSoC contractor shall be required to have an internal grievance system and internal appeal process. The appeal process allows a Medicaid recipient/enrollee to challenge a decision made, a denial of coverage, or a denial of payment for services.
2. B. An enrollee, an enrollee’s authorized representative or a provider on behalf of an enrollee, with the enrollee’s prior written consent, has 60 calendar days from the date on the notice of action in which to file an appeal.
3. C. An enrollee, an enrollee’s authorized representative or a provider on behalf of an enrollee, with the enrollee’s prior written consent, may file a grievance at any time after an occurrence or incident which is the basis for the grievance.
4. D. An enrollee must exhaust the MCO or the CSoC contractor grievance and appeal process before requesting a state fair hearing.
5. E. The MCO and CSoC contractor shall provide Medicaid enrollees with information about the state fair hearing process within the timeframes established by the department and in accordance with the state fair hearing policies.

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 38:363 (February 2012), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 41:2356 (November 2015), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43:322 (February 2017), LR 44:1890 (October 2018).