Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 120. Waivered Services
1/27/2020

12VAC30-120-430. Provider Grievances, Reconsiderations, and Appeals.

A. The MCOs shall comply with the requirements of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia), the provider appeals regulations at 12VAC30-20-500 through 12VAC30-20-560, the Medallion contract between DMAS and the MCO, and any other applicable state or federal statutory or regulatory requirements.

B. The MCOs shall have a grievance system established to respond to grievances made by network providers. Network provider grievances are not appealable to the DMAS Appeals Division.

C. MCOs shall, at the initiation of new network provider contracts, provide to every network provider the information described in this section concerning grievance, reconsideration, and appeal rights and procedures.

D. Disputes between the MCO and the network provider concerning any aspect of reimbursement shall be resolved through a verbal or written grievance or reconsideration process operated by the MCO or through the DMAS appeals process. A network provider or representative that is authorized by the network provider may act on behalf of a network provider in the MCO grievance or reconsideration or the DMAS appeals process.

E. Disputes arising solely from the MCO's denial or termination of a provider's enrollment in the MCO's network are not appealable to the DMAS Appeals Division.

F. If a network provider has rendered services to a member and has been denied authorization or reimbursement for the services or has received reduced authorization or reimbursement, that provider may request a reconsideration of the denied or reduced authorization or reimbursement. Before appealing to DMAS, network providers must first exhaust all MCO reconsideration processes. The MCO's final denial letter must include a statement that the provider has exhausted its reconsideration rights with the MCO and that the next level of appeal is with DMAS. The final denial letter must include the appeal rights to DMAS in accordance with the provider appeals regulations at 12VAC30-20-500 through 12VAC30-20-560.

G. All network provider appeals to DMAS must be submitted to the DMAS Appeals Division in writing and within 30 days of the MCO's last date of denial.

H. The MCO shall provide information necessary for any DMAS appeal within timeframes established by DMAS.

I. The MCO shall comply with the DMAS appeal decision. A DMAS appeal decision is not appealable by the MCO.

J. The MCO shall maintain a recordkeeping, reporting, and tracking system for complaints, grievances, and reconsiderations that complies with the Medallion contract between DMAS and the MCO. The system shall include a copy of the original complaint, grievance, or reconsideration; the decision; the nature of the decision; and data on the number of reconsiderations filed, the average time to resolve reconsiderations, and the total number of reconsiderations open as of the reporting date.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396.

Historical Notes

Derived from Volume 12, Issue 09, eff. January 1, 1996; reserved, Virginia Register Volume 13, Issue 05, eff. January 1, 1997; amended Virginia Register Volume 35, Issue 14, eff. April 18, 2019.

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