§ 108D-65 – (Effective until contingency met see note) Role of the Department.
108D-65. Role of the Department. The role and responsibility of the Department during Medicaid transformation shall include the following activities and functions: (1) Submit to CMS a demonstration waiver application pursuant to Section 1115 of the Social Security Act and any other waivers and State Plan amendments necessary to accomplish the requirements of this Article […]
§ 108D-15 – Contested case hearings on disputed adverse benefit determinations.
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.
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.
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 […]
§ 108D-21 – LME/MCO provider networks.
108D-21. LME/MCO provider networks. Each LME/MCO operating the combined 1915(b) and (c) waivers shall develop and maintain a closed network of providers to furnish mental health, intellectual or developmental disabilities, and substance abuse services to its enrollees. (2019-81, s. 1(a).)
§ 108D-5.7 – Notices.
108D-5.7. Notices. (a) Notices of Resolution. – For each disenrollment request by an enrollee or a PHP, the Department shall issue a written notice of resolution approving or denying the request by mail to the enrollee before the first day of the second month following the month in which the enrollee or PHP requested disenrollment. […]
§ 108D-5.9 – Appeals of adverse disenrollment determinations.
108D-5.9. Appeals of adverse disenrollment determinations. (a) Appeals. – An enrollee, or the enrollee’s authorized representative, who is dissatisfied with an adverse disenrollment determination may request a hearing to appeal the determination by filing the appeal request form provided under G.S. 108D-5.7(a) with the Office of Administrative Hearings within 30 calendar days of the date […]
§ 108D-11 – Managed care entity grievance and appeal procedures, generally.
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.
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.
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 […]