A. A managed care organization or dental benefit manager shall utilize uniform procedures established by the Authority under subsection B of this section for the review and appeal of any adverse determination by the managed care organization or dental benefit manager sought by any enrollee or provider adversely affected by such determination.
B. The Authority shall develop procedures for enrollee or providers to seek review by the managed care organization or dental benefit manager of any adverse determination made by the managed care organization or dental benefit manager. A provider shall have six (6) months from the receipt of a claim denial to file an appeal. With respect to appeals of adverse determinations made by a managed care organization or dental benefit manager on the basis of medical necessity, the following requirements shall apply:
1. Medical review staff of the managed care organization or dental benefit manager shall be licensed or credentialed health care clinicians with relevant clinical training or experience; and
2. All managed care organizations and dental benefit managers shall use medical review staff for such appeals and shall not use any automated claim review software or other automated functionality for such appeals.
C. Upon receipt of notice from the managed care organization or dental benefit manager that the adverse determination has been upheld on appeal, the enrollee or provider may request a fair hearing from the Authority. The Authority shall develop procedures for fair hearings in accordance with 42 C.F.R., Part 431.
Added by Laws 2021, c. 542, § 8, eff. Sept. 1, 2021.