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 grievance is an expression of dissatisfaction about any matter or aspect of Magnolia operation, other than an adverse benefit determination.
A member may file a grievance either orally or in writing with Magnolia any time after the grievance has occurred. Magnolia Health shall acknowledge receipt of each grievance in the manner in which is received. Any individuals who make a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, Magnolia Health 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] Magnolia Health 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.
Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the member’s health condition requires, not to exceed 30 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.
If the member is not satisfied with the initial grievance disposition, the member may request a Level II Grievance. The request must be submitted to Magnolia Health in writing within 30 calendar days of receipt of the written or verbal disposition. Magnolia will respond to the Level II Grievance in the same manner as stated in the initial grievance.
Medical Necessity Appeals
An appeal is the request for review of a “Adverse Benefit Determination.” A “Adverse Benefit Determination” is 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 his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Magnolia Health network.
Appeal Resolution Time Frame
Appeals may be requested orally or in writing by the member or the member’s representative within sixty (60) calendar days from the date on the Adverse Benefit Determination notice, with a 14 day extension possible if additional information is required. Members may request that Magnolia Health review the Adverse Benefit Determination to verify if the right decision has been made. Expedited appeals may be filed when either Magnolia Health 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 must be transferred to the timeframe for standard resolution of appeals.
Decisions for standard pre-service appeals are issued as expeditiously as the member’s health condition requires, but not exceeding thirty (30) calendar days from the initial receipt of the appeal.
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.
Magnolia Health may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Magnolia Health provides evidence satisfactory to the Division of Medicaid that a delay in rendering the decision is in the member’s interest. For any extension not requested by the member, Magnolia Health shall provide written notice to the member of the reason for the delay. Magnolia Health 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.