Timeline Standards -Beneficiary Problem Resolution

Category​​​​​​

Timeli​ne

W​ho

​​​Griev​ances

An expression of dissatisfaction about any matter other than an NOABD.

 

Filing

Any time

Beneficiaries or an authorized representative

Acknowledgement

5 calendar Days

Provider or MCP

Standard Resolution

90 calendar days

Provider or MCP

​Exempt Resolution

24 hours

Provider or MCP

​Expedited Resolution

72 hours

Provider or MCP

​Notice of Adverse Benefit Determination

A Notice Sent to Beneficiaries with regard to an action taken by the MCP which may adversely affect their services.

 

Termination, Suspension, or Reduction of
a previously authorized services​

At least 10 days before the date of action except permitted by other State and Federal exceptions to the beneficiary

Provider or MCP

Appeals

A review by an MCP of a NOABD.

 

Filing

60 calendar days of the date of NOABD

Beneficiaries or an authorized representative

Acknowledgement

5 calendar Days

MCP

Standard Resolution

30 calendar days

MCP

​Expedited Resolution

72 hours

MCP

​Extension

14 calendar days

MCP

Notification of Extension

  • ​  Reasonable efforts to provide prompt oral notice

  •   Written notice within 2 calendar days.

MCP

​Effectuation of Overturned Decisions

72 hours

MCP

​Internal Fair Hearings 

An equitable process to manage unsponsored beneficiary grievances and/or an appeal of a provider level grievance.

 

Filing​

120 days

Beneficiaries or authorized representative.​

Acknowledgement

5 calendar days

​Designated Investigator

​Standard Resolution

30 calendar days

​Designated Investigator

​Expedited Resolution

 ​72 hours

​Designated Investigator

Extension

14 calendar days

​Designated Investigator

Notification of Extension

  •  Reasonable efforts to provide prompt oral notice

  •   Written notice within 2 calendar days.

​Designated Investigator

​State Hearings

In response to the Notice of Appeal Resolution.​ 

 

Filing

120 days from NAR

Beneficiaries or authorized representative.

​Standard Resolution

90 calendar days

State Hearings Division

Expedited Resolution

3 working days

State Hearings Division

Effectuation of Overturned Decisions

72 hours

State Hearings Division

 

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