Amends GS 108D-1 to define adverse benefit determination (as defined in 42 CFR 438.400(b)), and to redefine contested case hearing to refer to adverse benefit determinations instead of managed care actions. Deletes the definition of managed care action. Replaces the term "notice of managed care action" with "adverse benefit determination."
Extends the period of an enrollee's right to request an LME/MCO level appeal to no later than 60 days (currently 30 days) after the mailing date of the required notice of an adverse benefit determination.
Directs LMC/MCO to resolve the appeal and provide written notice of resolution no later than 30 days (currently 45 days) after receiving the request.
Authorizes enrollees to request a contested case hearing if appeals have been exhausted under either GS 108D-14 or 42 CFR 438.408(c)(3) (currently just GS 108D-14).
Directs LME/MCO to resolve an expedited appeal and provide written notice of resolution no later than 72 hours after receiving the request (currently three working days).
Authorizes enrollees to request a contested case hearing if appeals have been exhausted under GS 108D-13 or GS 108D-14, or under 42 CFR 438.408(c)(3). Authorizes enrollee to file a request for an appeal to the Office of Administrative Hearings no later than 120 days (currently 30 days) after the mailing date of the notice of resolution.
Makes conforming changes, including replacing the term "managed care action" with the term "adverse benefit determination."
Bill S 161 (2017-2018)Summary date: Mar 1 2017 - More information
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