CurrentchpPolicy N/A

Appeals Process (GA-002)

Defines Community Health Plan of Imperial Valley's procedures and requirements for member appeals, including standard and expedited appeals, continuation of benefits (Aid Paid Pending), delegation to subcontractors, and related member rights. Affects CHPIV members, providers, authorized representatives, and delegated subcontractors (Health Net).

Policy Summary

Payerchp

PolicyAppeals Process (GA-002)

Policy CodePolicy N/A

Change TypeAnnual review — non‑material update

Effective Date6/12/2023

Next Review DateOct 2, 2025

Key ActionProviders may request an appeal on behalf of a member with the member's written consent within 60 calendar days of the notice of adverse benefit determination.

SourceLink

POLICY UPDATE CHANGES

Annual Review- added requirement HSC 1368.01(b) to immediately notify members of their right to notify DMHC of the appeal.

60 daysMember filing window

30 daysStandard resolution time

72 hoursExpedited decision max

14 daysMax extension

10 yrsRecord retention

8+Defined terms in excerpt

Appeals coverage criteria and operational rules

Covered when ALL of the following operational and member-rights criteria are met:

CHPIV maintains an internal appeal process (one level) in accordance with 42 CFR §§438.228 and 438.400-.424 and will assist members in preparing appeals, providing navigation assistance, documents relied upon, and the appeal form at no cost.

ALL of the following

A member has 60 calendar days from the date on the Notice of Adverse Benefit Determination/Notice of Action (NABD/NOA) to file an appeal either orally or in writing; a provider or authorized representative may file on the member's behalf with the member's written consent.
The contractor must resolve standard appeals within 30 calendar days of the member's oral or written request.
Expedited appeals must be resolved as expeditiously as the member's health condition requires and no later than 72 hours when the disputed services were not provided during the appeal.

Policy Summary

Payerchp

PolicyAppeals Process (GA-002)

Policy CodePolicy N/A

Change TypeAnnual review — non‑material update

Effective Date6/12/2023

Next Review DateOct 2, 2025

Key ActionProviders may request an appeal on behalf of a member with the member's written consent within 60 calendar days of the notice of adverse benefit determination.

SourceLink

On This Page

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ALL of the following

The member filed the appeal within the required Aid Paid Pending timeframe (within 10 calendar days of when the NOA/NABD was sent or before the intended effective date, whichever is later).
The appeal involves termination, suspension, or reduction of previously authorized covered services.
The covered services were ordered by an authorized provider.
The period covered by the original authorization has not expired.
Aid Paid Pending terminates when
- The member withdraws the appeal.
- GARS issues an appeal decision adverse to the member.
- The time period or service limits of the previously authorized service have been met.

Provider-initiated actions, expedited requests, and ABDs

Prior Authorization

Provider-initiated appeals: written consent and 60-day filing window

Providers may request an appeal on behalf of a member if they obtain the MEMBER's written consent; provider-initiated appeals must be submitted within 60 calendar days from the date of the NABD/NOA. Providers may also request an appeal on their own behalf within 60 calendar days after receipt of a denial for authorization or payment for services already received by the MEMBER. CHPIV must give providers (acting with the MEMBER's written consent) a reasonable opportunity to present evidence in writing or in person and must inform them of limited time available to present evidence for expedited appeals.

Provider may request an appeal on behalf of a MEMBER by submitting a written request within sixty (60) calendar days from the date of the NABD/NOA (with MEMBER's written consent).
Provider may request an appeal on their own behalf within sixty (60) calendar days after receipt of the denial for authorization or payment for services already received by the MEMBER.
CHPIV must allow providers (with MEMBER's written consent) to present evidence, testimony, facts, and law in support of the appeal and must inform them of limited timeframes for presenting evidence, including for expedited appeals.

Denial Risk

What constitutes an Adverse Benefit Determination (ABD)

An Adverse Benefit Determination (ABD) includes actions such as denial or limited authorization of a requested service; reduction, suspension, or termination of a previously authorized service; denial of payment (except clean-claim denials); failure to provide services in a timely manner; failure to act within required grievance and appeal timeframes; denial of out-of-network services in single-plan areas; and denial of a Member's request to dispute financial liability.

Denial or limited authorization of a requested service (including determinations based on type or level of a Covered Service or Medical Necessity).
Reduction, suspension, or termination of a previously authorized Covered Service.
Denial, in whole or in part, of payment for a Covered Service (excluding denials solely because the claim is not a clean claim).
Failure to provide Covered Services in a timely manner or to act within required timeframes for grievance and appeal resolution.
Denial of out-of-network services in single-plan areas or denial of dispute of financial liability.

Defined terms used in this policy

Adverse Benefit Determination (ABD)

DefinitionAdverse Benefit Determination (ABD): Means any of the following actions taken by Contractor: denial or limited authorization of a requested service (including determinations based on type or level of a Covered Service, Medical Necessity); the reduction, suspension, or termination of a previously authorized Covered Service; the denial, in whole or in part, of payment for a Covered Service (excluding denials solely because a claim is not a Clean Claim); failure to provide Covered Services in a timely manner; failure to act within required timeframes for grievance and appeal resolution; denial of out-of-network services in single-plan areas; or denial of a Member's request to dispute financial liability.

ScopeApplies to actions taken by Contractor that adversely affect a Member's access to or payment for Covered Services.

ExclusionA payment denial solely because the claim does not meet the definition of a Clean Claim is not an Adverse Benefit Determination.

Member

DefinitionMember: A beneficiary enrolled in a CHPIV program.

Enrollment contextCovers individuals enrolled in CHPIV and subject to CHPIV appeals and grievance processes.

Related rightsMembers have rights to file Grievances and Appeals, request State Fair Hearings, and appoint Authorized Representatives.

Authorized Representative

DefinitionAuthorized Representative: Any individual appointed in writing by a competent Member or Potential Member to act in place of or on behalf of the Member or Potential Member for purposes of assisting or representing the Member or Potential Member with Grievances and Appeals, State Fair Hearings, Independent Medical Reviews, and in any other capacity specified by the Member or Potential Member.

Form of appointmentMust be appointed in writing by the competent Member or Potential Member.

Authorized activitiesMay assist or represent the Member for appeals, grievances, SFHs, IMRs, and other specified capacities.

Corrective Action

DefinitionCorrective Action: Specific identifiable activities or undertakings of Contractor which address Contract deficiencies or noncompliance.

PurposeDesigned to remediate deficiencies and ensure contractual compliance.

ResponsibilityActions attributed to Contractor to correct identified noncompliance.

Adverse Benefit Determination (alternate)

ABD (alternate wording)Adverse Benefit Determination ('ABD') — Means denial or limited authorization of a requested service, including determinations based on the type or level of a Covered Service and Medical Necessity.

IncludesDenial or limitation of requested services and determinations based on service type/level or Medical Necessity.

ContextTerm appears capitalized in the policy; refer to Definitions section for usage.

Member (alternate)

Member (alternate)Member — A beneficiary enrolled in a CHPIV program.

UseTerm used throughout appeals and grievance processes to identify individuals with covered rights.

Enrollment implicationEligible to file Appeals, request Aid Paid Pending, and seek State Fair Hearings as provided by policy.

Authorized Representative (alternate)

Authorized Representative (alternate)Authorized Representative — Any individual appointed in writing by a competent Member or Potential Member to act in place of or on behalf of the Member or Potential Member for Grievances and Appeals, State Fair Hearings, Independent Medical Reviews, and other specified capacities.

Appointment requirementMust be an appointment in writing by the competent Member or Potential Member.

Representative rolesCan assist with filing, represent at hearings, and obtain records on behalf of the Member.

Corrective Action (alternate)

Corrective Action (alternate)Corrective Action — Means specific identifiable activities or undertakings of Contractor which address Contract deficiencies or noncompliance.

ObjectiveTo remediate identified issues and achieve compliance with contractual requirements.

AttributionRemedial activities are the responsibility of the Contractor.

Grievance

DefinitionGrievance: An oral or written expression of dissatisfaction about any matter other than an ABD; may include quality of care or services, interpersonal relationships with a Provider or Contractor employee, failure to respect a Member's rights (regardless of whether remedial action is requested), and disputes over time extensions for authorization decisions.

ScopeCovers non-ABD matters including service quality, staff interactions, and rights violations.

FormMay be submitted orally or in writing.

State Fair Hearing (SFH)

DefinitionState Fair Hearing (SFH): A hearing with a State Administrative Law Judge to resolve a member's dispute about an action taken by Contractor, its Network Providers, Subcontractors, or Downstream Subcontractors.

PurposeProvides an external administrative review to resolve disputes not resolved through internal appeals.

ParticipantsInvolves the Member (or Authorized Representative), the Contractor, and the State Administrative Law Judge.