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A. Federal law requires that Medicaid MCOs have a system in place for enrollees that includes a grievance process, an appeal process, and access to an administrative fair hearing through the State Administrative Fair Hearing Process. For in-plan services, RHP members must exhaust the internal MCO Level I and Level II appeals process before requesting an EOHHS hearing. Regulations governing the appeals process for out-of-plan services are found in Part 10-05-2 of this Title. 1. Types of Internal Appeals – The plan must maintain internal policies and procedures to conform to state reporting policies and implement a process for logging appeals. Appeals filed with a managed care plan fall into three (3) categories: a. Medical Emergency. An MCO must decide the appeal within seventy-two (72) hours when a treating provider, such as a doctor who takes care of the member, determines the care to be an emergency and all necessary information has been received by the MCO. b. Non-Emergency Medical Care. The two (2) levels of a non- emergency medical care appeal are as follows: (1) For the initial level of appeal, the MCO must decide the appeal within fifteen (15) days from the date that all necessary information is dated as received by the MCO. If the initial decision is adverse to the member, then the MCO must offer the second (2nd) level of appeal. (2) For the second (2nd) level of appeal, the MCO must make a decision within fifteen (15) days of the date that all necessary information is dated as received by the MCO. c. Non-Medical Care. If the appeal involves a problem other than medical care, the MCO must resolve the appeal within thirty (30) days of the date that all necessary information is dated as received by the MCO. 2. External Appeal. RHP members who exhaust the health plan’s internal appeal processes may choose to initiate an “external appeal,” in accordance with Part 10-05-5 of this Title. A member does not have to exhaust the third (3rd) level appeal before accessing an EOHHS hearing. 3. Regulations governing the appeals process are found in Part 10-05-2 of this Title.