PURPOSE: This rule sets forth the process to appeal from the denial of or termination from participation in the Missouri Senior Rx Program.

1. (1) Applicants for, or claimants of, program benefits shall have the right to appeal the denial of an application for benefits or termination from the program, except for a denial or termination because the applicant or claimant has refused to submit requested information or documentation or any other information necessary to establish eligibility for the program or a termination as a result of the end of a plan (fiscal) year. Applicants for, or claimants of, program benefits shall not have the right to appeal the implementation of any cost-control measures.

2. (2) The third-party administrator shall provide written notice of the denial or termination directly to the applicant or claimant or their authorized agent.

   1. (A) The notice shall include the reasons for the denial or termination;
   2. (B) A notice of termination shall be effective no sooner than ten (10) calendar days after the date of the notice;
   3. (C) The denial or termination may be appealed;
   4. (D) If an appeal is made, such appeal shall be filed with the third-party administrator within thirty (30) calendar days following the date of the notice of denial or termination of program benefits.

3. (3) Applicant or claimant shall file an appeal within thirty (30) calendar days following the date of the notice of denial or termination with the third-party administrator.

   1. (A) In the case of appeal of a termination of program benefits, filing of an appeal within the allowed thirty (30) calendar days shall continue benefits from the date the appeal is received by the third-party administrator until the end of the appeal process.
   2. (B) The appeal shall include the applicant’s or claimant’s name, address, telephone number, program enrollment number, and the reasons for the appeal.

4. (4) The third-party administrator will initially seek to resolve all applicant or claimant appeals through a letter-ruling process.

   1. (A) The letter-ruling process shall consist of the following steps:

      1. 1. The third-party administrator shall

review the denial or termination, including a review of applicable documentation, to determine any possibility of an error.

1. 2. Within thirty (30) calendar days of the

receipt of the appeal, a letter shall be sent to the applicant or claimant which sets forth the results of the review. The letter will cite the reason for the results of the review and 19 CSR 90-1

inform the applicant or claimant of the right to a formal hearing before the third-party administrator.

1. (B) Results and opinions set forth in letter rulings shall have no precedential authority and are subject to withdrawal or change at any time to conform with new or different interpretations of the law.

1. (5) If an applicant or claimant who has filed an appeal under section (3) of this rule disagrees with the third-party administrator’s letter ruling, the applicant or claimant may request a formal hearing on the appeal.

   1. (A) The applicant or claimant shall file a written request for a formal hearing within ten (10) calendar days of the date of the letter ruling by the third-party administrator.
   2. (B) When the third-party administrator receives the formal request for a hearing, the third-party administrator shall appoint a hearing officer to address and preside over the formal hearing.
2. (6) The authorized agent shall have the right to file an appeal on behalf of the applicant or claimant.
3. (7) If the claimant does not prevail in his or her appeal, the commission reserves the right to recoup any program benefits received by the claimant during the appeal process.

AUTHORITY: section 208.553.3(5), RSMo Supp. 2001.* Emergency rule filed Jan. 16, 2002, effective March 1, 2002, expired Aug. 27, 2002. Original rule filed Jan. 16, 2002, effective Aug. 30, 2002. *Original authority: 208.553, RSMo 2001.