Page 24
LTSS and behavioral health) may be made to the EOHHS Hearing Office and/or to the Rhode Island External Review Entity per State Regulations (Part 10-05-2 of this Title) after the first (1st) plan-level Appeal has been completed. If an appeal is filed with both the Rhode Island External Review Entity and the EOHHS Hearing Office, the MCO will be bound by any determination in favor of the member that is closest to the relief requested by the member. Appeals related to drugs excluded from Medicare Part D that are covered by Medicaid must be filed with the MMP in accordance with Part 10-05-2 of this Title, and Subchapter 00 Part 2 of this Chapter, and the requirements contained herein. c. Services covered by both Medicare and Medicaid. After the first (1st) level internal appeal, appeals for services for which Medicare and Medicaid overlap (including, but not limited to, home health, durable medical equipment, and skilled therapies, but excluding Part D) will be auto-forwarded to the IRE by the MMP. d. After the first (1st) plan-level appeal for Medicare and Medicaid overlapping services, a member may file a request for a hearing with the EOHHS State Fair Hearing Office. After the first (1st) plan- level appeal for Medicare and Medicaid overlap services, a member may also file a request for a hearing with the Rhode Island External Review Entity per State Regulations (Part 10-05-2 of this Title). If an appeal is filed with both the IRE and either the Rhode Island External Review Entity or the EOHHS Hearing Office, the MCO will be bound by any determination in favor of the member that is closest to the relief requested by the member. 3. Internal appeals timeframes a. First (1st) Level. An MMP member must file a first (1st) level internal appeal with the plan within sixty (60) calendar days following the date of the notice of adverse action that generates the appeal. b. Standard appeals. For first (1st) level internal appeals, the MMP must render a decision within thirty (30) calendar days of the date that the appeal request has been received by the managed care entity. The MMP can extend the deadline for a decision by up to fourteen (14) days if requested by the beneficiary or if the delay is in the beneficiary’s best interest. c. Expedited appeals. For first (1st) level internal appeals, the MMP must render a decision within seventy-two (72) hours of the date that the appeal request has been received by the managed care entity when either the MMP or the member’s provider determines that standard appeal resolution could seriously jeopardize the