[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: 42CFR438.404]



[Page 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.  438.404  Notice of action.



    (a) Language and format requirements. The notice must be in writing 

and must meet the language and format requirements of Sec.  438.10(c) 

and (d) to ensure ease of understanding.

    (b) Content of notice. The notice must explain the following:

    (1) The action the MCO or PIHP or its contractor has taken or 

intends to take.

    (2) The reasons for the action.

    (3) The enrollee's or the provider's right to file an MCO or PIHP 

appeal.

    (4) If the State does not require the enrollee to exhaust the MCO or 

PIHP level appeal procedures, the enrollee's right to request a State 

fair hearing.

    (5) The procedures for exercising the rights specified in this 

paragraph.

    (6) The circumstances under which expedited resolution is available 

and how to request it.

    (7) The enrollee's right to have benefits continue pending 

resolution of the appeal, how to request that benefits be continued, and 

the circumstances under which the enrollee may be required to pay the 

costs of these services.

    (c) Timing of notice. The MCO or PIHP must mail the notice within 

the following timeframes:

    (1) For termination, suspension, or reduction of previously 

authorized Medicaid-covered services, within the timeframes specified in 

Sec. Sec.  431.211, 431.213, and 431.214 of this chapter.

    (2) For denial of payment, at the time of any action affecting the 

claim.

    (3) For standard service authorization decisions that deny or limit 

services, within the timeframe specified in Sec.  438.210(d)(1).

    (4) If the MCO or PIHP extends the timeframe in accordance with 

Sec.  438.210(d)(1), it must--

    (i) Give the enrollee written notice of the reason for the decision 

to extend the timeframe and inform the enrollee of the right to file a 

grievance if he or she disagrees with that decision; and

    (ii) Issue and carry out its determination as expeditiously as the 

enrollee's health condition requires and no later than the date the 

extension expires.

    (5) For service authorization decisions not reached within the 

timeframes specified in Sec.  438.210(d) (which constitutes a denial and 

is thus an adverse action), on the date that the timeframes expire.

    (6) For expedited service authorization decisions, within the 

timeframes specified in Sec.  438.210(d).