Timeline Standards -Beneficiary Problem Resolution
Category |
Timeline |
Who |
Grievances |
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 |
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 |
|
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 |
|
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 |