§ 22-6-225 — Denial of Claims; Grievances and Appeals

(a) The Medicaid Agency shall establish by rule procedures for safeguarding against wrongful denial of claims and addressing grievances of enrollees in an integrated care network.
(b) If a patient or the provider is dissatisfied with the decision of an integrated care network, the patient or provider may file a written notice of appeal to the Medicaid Agency. The Medicaid Agency shall adopt rules governing the appeal, which shall include a full evidentiary hearing and a finding on the record. The Medicaid Agency’s decision shall be binding upon the integrated care network. However, a patient or provider may file an appeal in circuit court in the county in which the patient resides, or the county in which the provider provides services.
(c) The Medicaid Agency shall by rule establish procedures for addressing grievances and appeals of the integrated care network. The appeal procedure shall include an opportunity for a fair hearing before an impartial hearing officer in accordance with the Administrative Procedure Act, Chapter 22 of Title 41. The state Medicaid Commissioner shall appoint one, or more than one, hearing officer to conduct fair hearings. After each hearing, the findings and recommendations of the hearing officer shall be submitted to the Commissioner, who shall make a final decision for the agency. Judicial review of the final decision of the Medicaid Agency may be sought pursuant to the Administrative Procedure Act. All costs related to development and implementation of the appeal procedure, including the provision of administrative hearings, shall be borne by the Medicaid Agency. The Medicaid Agency shall adopt rules for implementing this subsection in accordance with the Administrative Procedure Act.

Legislative History

(Act 2015-322, §7.)