[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: 42CFR438.402]



[Page 237-238]

 

                         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.  438.402  General requirements.



    (a) The grievance system. Each MCO and PIHP must have a system in 

place for enrollees that includes a grievance process, an appeal 

process, and access to the State's fair hearing system.

    (b) Filing requirements--(1) Authority to file. (i) An enrollee may 

file a grievance and an MCO or PIHP level appeal, and may request a 

State fair hearing.

    (ii) A provider, acting on behalf of the enrollee and with the 

enrollee's written consent, may file an appeal. A provider may file a 

grievance or request a State fair hearing on behalf of an enrollee, if 

the State permits the provider to act as the enrollee's authorized 

representative in doing so.

    (2) Timing. The State specifies a reasonable timeframe that may be 

no less than 20 days and not to exceed 90 days from the date on the 

MCO's or PIHP's notice of action. Within that timeframe--

    (i) The enrollee or the provider may file an appeal; and

    (ii) In a State that does not require exhaustion of MCO and PIHP 

level appeals, the enrollee may request a State fair hearing.

    (3) Procedures. (i) The enrollee may file a grievance either orally 

or in writing and, as determined by the State, either with the State or 

with the MCO or the PIHP.



[[Page 238]]



    (ii) The enrollee or the provider may file an appeal either orally 

or in writing, and unless he or she requests expedited resolution, must 

follow an oral filing with a written, signed, appeal.