Grievance and Appeals Process
The grievance process allows the member, (or the member’s authorized representative (family member, etc.) acting on behalf of the member or provider acting on the member’s behalf with the member’s written consent), to file a grievance either orally or in writing. A member grievance is defined as any member expression of dissatisfaction about any matter other than an “adverse action.”
NH Healthy Families shall acknowledge receipt of each grievance in writing with 10 business days from the receipt date.
Types of grievances include but are not limited to:
- Dissatisfaction with the quality of care or services the member received;
- Dissatisfaction with the way the member was treated by the plan or its network providers;
- Dispute of an extension of time proposed by the plan to make an authorization or appeal decision.
Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the member’s health condition requires, not to exceed 45 calendar days from the date of the initial receipt of the grievance. Expedited grievance reviews will be available for members in situations deemed urgent, such as a denial of an expedited appeal request, and will be resolved within 72 hours.
NH Healthy Families values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf.
Medical Necessity Appeals
An appeal is the request for review of a coverage decision, such as the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise their right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the NH Healthy Families network.
The member has 60 calendar days from the date of notice of action or inaction to file an appeal. NH Healthy Families shall acknowledge receipt of each appeal in writing within 10 business days from the receipt date. Any individuals who make a decision on appeals will not be involved in any previous level of review or decision making. In any case where the reason for the appeal involves clinical issues, NH Healthy Families shall ensure that the decision makers are healthcare
professionals with the appropriate clinical expertise in treating the member’s condition or disease. [42 CFR § 438.406]
Appeal Resolution Time Frame
The review may be requested in writing or orally, however all requests for appeals within the standard timeframe must be resolved within 30 calendar days of receipt of the appeal, with a 14 day extension possible if additional information is required or the extension is in the member’s best interest. Expedited appeals may be filed when either NH Healthy Families or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal is transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. NH Healthy Families may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if NH Healthy Families provides evidence satisfactory to the Department of Health and Human Services (DHHS) if requested that a delay in rendering the decision is in the member’s interest. For any extension not requested by the member, NH Healthy Families shall provide written notice to the member of the reason for the delay. NH Healthy Families shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow up within two calendar days with a written notice of action.