us-wi/statute/49.45/5 — Appeal.

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us-wi/statute/49.45/5 — Appeal. · Axiom

(ag)#

A person shall request a hearing within 90 days of the date of receipt of a notice from a care management organization or managed care organization upholding its adverse benefit determination relating to any of the following or within 90 days of the date the care management organization or managed care organization failed to act on the contested matter within the time specified by the department: 1. Denial or limited authorization of a requested services, including a determination based on the type or level of service, requirement for medical necessity, appropriateness, setting, or effectiveness of a covered benefit. 2. Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed. 3. Denial, in whole or in part, of payment for a service. 4. Failure to provide services in a timely manner. 5. Failure of a care management organization or managed care organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals. 6. Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities. 7. Denial of an enrollee, who is a resident of a rural area with only one care management organization or managed care organization, to obtain services outside the organization’s network of contracted providers.

(ag)(1)#

Denial or limited authorization of a requested services, including a determination based on the type or level of service, requirement for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

(ag)(2)#

Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.

(ag)(3)#

Denial, in whole or in part, of payment for a service.

(ag)(4)#

Failure to provide services in a timely manner.

(ag)(5)#

Failure of a care management organization or managed care organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

(ag)(6)#

Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

(ag)(7)#

Denial of an enrollee, who is a resident of a rural area with only one care management organization or managed care organization, to obtain services outside the organization’s network of contracted providers.

(b)#

1. Upon receipt of a timely petition under par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if: a. The petitioner withdraws the petition in writing. b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law. c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department. d. The issue is an adverse benefit determination described in par. (ag) 1. to 7. made by a care management organization or managed care organization and the person requesting the hearing has not exhausted the internal appeal procedure with the organization. 2. If a recipient requests a hearing within the timely notice period specified in 42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the county department of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced, or discontinued if: a. The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient’s behalf. b. The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change. 3. The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.

(b)(1)#

Upon receipt of a timely petition under par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if: a. The petitioner withdraws the petition in writing. b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law. c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department. d. The issue is an adverse benefit determination described in par. (ag) 1. to 7. made by a care management organization or managed care organization and the person requesting the hearing has not exhausted the internal appeal procedure with the organization.

(b)(1)(a)#

The petitioner withdraws the petition in writing.

(b)(1)(b)#

The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.

(b)(1)(c)#

The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department.

(b)(1)(d)#

The issue is an adverse benefit determination described in par. (ag) 1. to 7. made by a care management organization or managed care organization and the person requesting the hearing has not exhausted the internal appeal procedure with the organization.

(b)(2)#

If a recipient requests a hearing within the timely notice period specified in 42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the county department of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced, or discontinued if: a. The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient’s behalf. b. The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.

(b)(2)(a)#

The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient’s behalf.

(b)(2)(b)#

The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.

(b)(3)#

The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.