[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.400]



[Page 237]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                       Subpart F_Grievance System

 

Sec.  438.400  Statutory basis and definitions.





    (a) Statutory basis. This subpart is based on sections 1902(a)(3), 

1902(a)(4), and 1932(b)(4) of the Act.

    (1) Section 1902(a)(3) requires that a State plan provide an 

opportunity for a fair hearing to any person whose claim for assistance 

is denied or not acted upon promptly.

    (2) Section 1902(a)(4) requires that the State plan provide for 

methods of administration that the Secretary finds necessary for the 

proper and efficient operation of the plan.

    (3) Section 1932(b)(4) requires Medicaid managed care organizations 

to establish internal grievance procedures under which Medicaid 

enrollees, or providers acting on their behalf, may challenge the denial 

of coverage of, or payment for, medical assistance.

    (b) Definitions. As used in this subpart, the following terms have 

the indicated meanings:

    Action means--

    In the case of an MCO or PIHP--

    (1) The denial or limited authorization of a requested service, 

including the type or level of service;

    (2) The reduction, suspension, or termination of a previously 

authorized service;

    (3) The denial, in whole or in part, of payment for a service;

    (4) The failure to provide services in a timely manner, as defined 

by the State;

    (5) The failure of an MCO or PIHP to act within the timeframes 

provided in Sec.  438.408(b); or

    (6) For a resident of a rural area with only one MCO, the denial of 

a Medicaid enrollee's request to exercise his or her right, under Sec.  

438.52(b)(2)(ii), to obtain services outside the network.

    Appeal means a request for review of an action, as ``action'' is 

defined in this section.

    Grievance means an expression of dissatisfaction about any matter 

other than an action, as ``action'' is defined in this section. The term 

is also used to refer to the overall system that includes grievances and 

appeals handled at the MCO or PIHP level and access to the State fair 

hearing process. (Possible subjects for grievances include, but are not 

limited to, the quality of care or services provided, and aspects of 

interpersonal relationships such as rudeness of a provider or employee, 

or failure to respect the enrollee's rights.)