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

1. (1) Applicants for the program or enrolled participating pharmacies shall have the right to appeal the denial of an application for or suspension or termination from the program, except for a denial, suspension or termination because the applicant 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.

2. (2) The third-party administrator shall provide written notice of the denial, termination, or suspension directly to the applicant or participating pharmacy.

   1. (A) The notice shall include the reasons for the denial, termination or suspension;
   2. (B) A notice of termination or suspension shall be effective no sooner than ten (10) calendar days after the date of the notice;
   3. (C) The denial, termination or suspension 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, suspension or termination from the program.

3. (3) An applicant or participating pharmacy shall file an appeal within thirty (30) calendar days following the date of the notice of denial, suspension or termination with the third-party administrator.

   1. (A) In the case of appeal of a termination or suspension from the program, filing of an appeal within the allowed thirty (30) calendar days shall continue participation in the program from the date the appeal is received by the third-party administrator.
   2. (B) The appeal shall include the applicant’s or participating pharmacy’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 participating pharmacy’s 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, suspension 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 participating pharmacy which sets forth the results of the review. The letter will cite the reason for the results of the review and inform the applicant or participating pharmacy 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 participating pharmacy who has filed an appeal under section (3) of this rule disagrees with the third-party administrator’s letter ruling, the applicant or participating pharmacy may request a formal hearing on the appeal.

   1. (A) The applicant or participating pharmacy 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) If a participating pharmacy does not prevail in its appeal, the commission reserves the right to recoup any funds received under the program during the appeal process.
3. (7) If a participating pharmacy has been terminated from the program, the pharmacy may be enrolled upon agreement by the thirdparty administrator.

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.