(a)
General rule. An applicable integrated plan may only have one level of integrated reconsideration for an enrollee.
(b)
External medical reviews. If a State has established an external medical review process, the requirements of
§ 438.402(c)(1)(i)(B) of this chapter apply to each applicable integrated plan that is a Medicaid managed care organization, as defined in
section 1903 of the Act.
(c)
Case file. Upon request of the enrollee or his or her representative, the applicable integrated plan must provide the enrollee and his or her representative the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the applicable integrated plan (or at the direction of the applicable integrated plan) in connection with the appeal of the integrated organization determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for the integrated reconsideration, or subsequent appeal, as specified in this section.
(d)
Timing.
(1)
Timeframe for filing— An enrollee has 60 calendar days after receipt of the adverse organization determination notice to file a request for an integrated reconsideration with the applicable integrated plan.
(i)
The date of receipt of the adverse organization determination is presumed to be 5 calendar days after the date of the integrated organization determination notice, unless there is evidence to the contrary.
(ii)
For purposes of meeting the 60-calendar day filing deadline, the request is considered as filed on the date it is received by the applicable integrated plan.
(2)
Oral inquires— Oral inquires seeking to appeal an adverse integrated organization determination must be treated as a request for an integrated reconsideration (to establish the earliest possible filing date for the appeal).
(3)
Extending the time for filing a request—
(i)
General rule. If a party or physician acting on behalf of an enrollee shows good cause, the applicable integrated plan may extend the timeframe for filing a request for an integrated reconsideration.
(ii)
How to request an extension of timeframe. If the 60-day period in which to file a request for an integrated reconsideration has expired, a party to the integrated organization determination or a physician acting on behalf of an enrollee may file a request for integrated reconsideration with the applicable integrated plan. The request for integrated reconsideration and to extend the timeframe must—
(B)
State why the request for integrated reconsideration was not filed on time.
(e)
Expedited integrated reconsiderations.
(1)
Applicable integrated plans must accept requests to expedite integrated reconsiderations from either of the following:
(ii)
A provider making the request on behalf of an enrollee, when the request is not a request for expedited payment.
(2)
The request can be oral or in writing.
(3)
The applicable integrated plan must grant the request to expedite the integrated reconsideration when it determines (for a request from the enrollee), or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request), that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function.
(4)
If an applicable integrated plan denies an enrollee's request for an expedited integrated reconsideration, it must automatically transfer a request to the standard timeframe and make the determination within the 30-day timeframe established in
paragraph (f)(1) of this section for a standard integrated reconsideration. The 30-day period begins with the day the applicable integrated plan receives the request for expedited integrated reconsideration. The applicable integrated plan must give the enrollee prompt oral notice of the decision, and give the enrollee written notice within 2 calendar days. The written notice must do all of the following:
(i)
Include the reason for the denial.
(ii)
Inform the enrollee of the right to file a grievance if the enrollee disagrees with the decision not to expedite, including timeframes and procedures for filing a grievance.
(iii)
Inform the enrollee of the right to resubmit a request for an expedited determination with any physician's support.
(5)
If the applicable integrated plan must receive medical information from noncontract providers, the applicable integrated plan must request the necessary information from the noncontract provider within 24 hours of the initial request for an expedited integrated reconsideration. Noncontract providers must make reasonable and diligent efforts to expeditiously gather and forward all necessary information to assist the applicable integrated plan in meeting the required timeframe. Regardless of whether the applicable integrated plan must request information from noncontract providers, the applicable integrated plan is responsible for meeting the timeframe and notice requirements of this section.
(f)
Resolution and notification. The applicable integrated plan must make integrated reconsidered determinations as expeditiously as the enrollee's health condition requires but no later than the timeframes established in this section. Integrated reconsidered determinations regarding Part B drugs must comply with the timelines governing Part B drugs established in §§
422.584(d)(1) and
422.590(c) and
(e)(2).
(1)
Standard integrated reconsiderations. The applicable integrated plan must resolve integrated reconsiderations as expeditiously as the enrollee's health condition requires but no later than 30 calendar days from the date of receipt of the request for the integrated reconsideration. This timeframe may be extended as described in
paragraph (f)(3) of this section.
(2)
Expedited integrated reconsiderations. The applicable integrated plan must resolve expedited integrated reconsiderations as expeditiously as the enrollee's health condition requires but no later than within 72 hours of receipt of the integrated reconsideration. This timeframe may be extended as described in
paragraph (f)(3) of this section. In addition to the written notice required under
paragraph (f)(4) of this section, the applicable integrated plan must make reasonable efforts to provide prompt oral notice of the expedited resolution to the enrollee.
(3)
Extensions.
(i)
The applicable integrated plan may extend the timeframe for resolving any integrated reconsideration other than those concerning Part B drugs by 14 calendar days if—
(A)
The enrollee requests the extension; or
(B)
The applicable integrated plan can show that— (1) The extension is in the enrollee's interest; and
(2) There is need for additional information and there is a reasonable likelihood that receipt of such information would lead to approval of the request, if received.
(ii)
If the applicable integrated plan extends the timeframe for resolving the integrated reconsideration, it must make reasonable efforts to give the enrollee prompt oral notice of the delay, and give the enrollee written notice within 2 calendar days of making the decision to extend the timeframe to resolve the integrated reconsideration. The notice must include the reason for the delay and inform the enrollee of the right to file an expedited grievance if he or she disagrees with the decision to grant an extension.
(4)
Notice of resolution. The applicable integrated plan must send a written notice to enrollees that includes the integrated reconsidered determination, within the resolution timeframes set forth in this section. The notice of determination must be written in plain language and available in a language and format that is accessible to the enrollee and must explain the following:
(i)
The resolution of and basis for the integrated reconsideration and the date it was completed.
(ii)
For integrated reconsiderations not resolved wholly in favor of the enrollee—
(A)
An explanation of the next level of appeal available under the Medicare and Medicaid programs, and what steps the enrollee must take to pursue the next level of appeal under each program, and how the enrollee can obtain assistance in pursuing the next level of appeal under each program; and
(B)
The right to request and receive Medicaid-covered benefits while the next level of appeal is pending, if applicable.
(g)
Withdrawing a request. The party or physician acting on behalf of an enrollee who files a request for integrated reconsideration may withdraw it by filing a request for withdrawal with the applicable integrated plan.
(h)
Dismissing a request. The applicable integrated plan dismisses an expedited or standard integrated reconsideration request, either entirely or as to any stated issue, under any of the following circumstances:
(1)
The person or entity requesting an integrated reconsideration is not a proper party to request an integrated reconsideration under
§ 422.629(l).
(2)
The applicable integrated plan determines the party failed to make a valid request for an integrated reconsideration that substantially complies with
§ 422.629(l) of this section.
(3)
The party fails to file the integrated reconsideration request within the proper filing timeframe in accordance with
paragraph (d) of this section.
(4)
The enrollee or the enrollee's representative files a request for an integrated reconsideration, but the enrollee dies while the request is pending, and both of the following criteria apply:
(i)
The enrollee's surviving spouse or estate has no remaining financial interest in the case.
(ii)
No other individual or entity with a financial interest in the case wishes to pursue the integrated reconsideration.
(5)
A party filing the reconsideration request submits a timely request for withdrawal of their request for an integrated reconsideration with the applicable integrated plan.
(i)
Notice of dismissal. The applicable integrated plan must mail or otherwise transmit a written notice of the dismissal of the integrated reconsideration request to the parties. The notice must state all of the following:
(1)
The reason for the dismissal.
(2)
The right to request that the applicable integrated plan vacate the dismissal action.
(3)
The right to request review of the dismissal by the independent entity.
(j)
Vacating a dismissal. If good cause is established, the applicable integrated plan may vacate its dismissal of a request for integrated reconsideration within 6 months from the date of the notice of dismissal.
(k)
Effect of dismissal. The applicable integrated plan's dismissal is binding unless the enrollee or other party requests review by the independent entity in accordance with
§ 422.590(h) or the dismissal is vacated under
paragraph (j) of this section.
Notes, amendments, and revision history
Amendments
[84 FR 15835, Apr. 16, 2019, as amended at 84 FR 23883, May 23, 2019; 84 FR 26579, June 7, 2019; 86 FR 6103, Jan. 19, 2021; 87 FR 27897, May 9, 2022; 89 FR 30827, Apr. 23, 2024]
Source
Source: 84 FR 15835, Apr. 16, 2019, unless otherwise noted.
Source
Source: 63 FR 35107, June 26, 1998, unless otherwise noted.
Authority
Authority: 42 U.S.C. 1302, 1306, 1395w-21 through 1395w-28, and 1395hh.
Source
Source: 63 FR 18134, Apr. 14, 1998, unless otherwise noted.
Amendments
[84 FR 15835, Apr. 16, 2019, as amended at 84 FR 23883, May 23, 2019; 84 FR 26579, June 7, 2019; 86 FR 6103, Jan. 19, 2021; 87 FR 27897, May 9, 2022; 89 FR 30827, Apr. 23, 2024]