10A NCAC 27G .7004      APPEALS REGARDING UTILIZATION REVIEW DECISIONS FOR NON-MEDICAID SERVICES

(a)  This Rule governs appeals made to the Local Management Entity Director of utilization review decisions made by the Local Management Entity to deny, reduce, suspend or terminate a client's non-Medicaid funded services.

(b)  A client may appeal to the Local Management Entity Director the utilization review decision of a Local Management Entity to deny, reduce suspend, or terminate a non-Medicaid state funded service.

(c)  The Local Management Entity shall send to the client or legal representative(s) notification letters regarding utilization review decisions for non-Medicaid funded services. The letter shall be dated and mailed no later than the next work day following the review decision to deny, reduce, suspend, or terminate a non-Medicaid state funded service. The Local Management Entity shall separately notify the provider regarding the service authorization.

(d)  The letter shall include information regarding the reason for the decision and any available options or considerations while the appeal is under review.

(e)  An appeal regarding a non-Medicaid services utilization review decision must be filed only by a client or legal representative. The appeal must be received in writing by the Local Management Entity within 15 working days of the date of the notification letter. The Local Management Entity shall provide help to an appellant who requests assistance in filing the appeal.

(f)  The Local Management Entity shall acknowledge receipt of the appeal in writing in a letter to the appellant dated the next working day after receipt of the appeal.

(g)  The Local Management Entity may authorize interim services until the final review decision, as set forth in 10A NCAC 27I .0609, is reached.

(h)  The clinical review shall be conducted by an employee(s) or contractor(s) of the Local Management Entity not involved in the utilization review decision that is the subject of the appeal. The clinical reviewer(s) clinical credentials shall be at least comparable to those of the person who rendered the initial utilization review decision.

(i)  The clinical reviewer(s) shall complete a clinical review of the appeal and shall uphold or overturn the original decision.

(j)  The Local Management Entity shall notify the appellant in writing of the clinical review decision in a letter dated and mailed within seven working days from receipt of the appeal request and shall separately notify the provider regarding the service authorization.

(k)  If the clinical review overturns the initial utilization review decision, the decision letter shall state the date on which the denied service shall be authorized or the date on which the suspended, reduced or terminated service shall be reinstated.

(l)  In cases in which the decision upholds the previous decision, the Local Management Entity shall inform appellants in writing of the opportunity to appeal a decision regarding a non-Medicaid service to the State Division of Mental Health, Developmental Disabilities and Substance Abuse Services Non-Medicaid Appeals Panel according to 10A NCAC 27I .0600 and G.S. 143B-147(a)(9).

History Note:        Authority G.S. 122C-112.1(a)(29);

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 20, 2019.