108D-11. Managed care entity grievance and appeal procedures, generally. (a) Each managed care entity shall establish and maintain internal grievance and appeal procedures that (i) comply with the Social Security Act and 42 C.F.R. Part 438, Subpart F, and (ii) afford enrollees and their authorized representatives constitutional rights to due process and a fair hearing. […]
108D-12. Managed care entity grievances. (a) Filing of Grievance. – An enrollee, or the enrollee’s authorized representative, has the right to file a grievance with a managed care entity at any time to express dissatisfaction about any matter other than an adverse benefit determination. Upon receipt of a grievance, a managed care entity shall cause […]
108D-13. Standard managed care entity level appeals. (a) Notice of Adverse Benefit Determination. – A managed care entity shall provide an enrollee with a written notice of an adverse benefit determination by mail as required under 42 C.F.R. 438.404. The notice will employ a standardized form included as a provision in the contract between the […]
108D-14. Expedited managed care entity level appeals. (a) Request for Expedited Appeal. – When the time limits for completing a standard managed care entity level appeal under G.S. 108D-13 could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, an enrollee, or the enrollee’s authorized representative, has the […]
108D-15. Contested case hearings on disputed adverse benefit determinations. (a) Jurisdiction of the Office of Administrative Hearings. – The Office of Administrative Hearings does not have jurisdiction over a dispute concerning an adverse benefit determination, except as expressly set forth in this Chapter. (b) Exclusive Administrative Remedy. – Notwithstanding any provision of State law or […]
108D-15.1. Expedited contested case hearings on disputed adverse benefit determinations. In accordance with 42 C.F.R. 431.224, an enrollee, or an enrollee’s authorized representative, may request that an appeal under G.S. 108D-15(d) be expedited if the time otherwise permitted for a hearing could jeopardize the enrollee’s life, health, or ability to attain, maintain, or regain maximum […]
108D-16. Notice of final decision and right to seek judicial review. The administrative law judge assigned to conduct a contested case hearing under G.S. 108D-15 shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision that includes findings of fact and conclusions of law and send it to the […]
