42 Public Health 3 2001-10-01 2001-10-01 false Effectuation of reversed appeal resolutions. 438.424 Section 438.424 Public Health CENTERS FOR MEDICARE &MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES-(Continued) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE PROVISIONS Grievance System
ยง 438.424 Effectuation of reversed appeal resolutions.

(a) Services not furnished while the appeal is pending. If the MCO or PHP, or the State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO or PHP must authorize or provide the disputed services promptly, and as expeditiously as the enrollee's health condition requires.

(b) Services furnished while the appeal is pending. If the MCO or PHP, or the State fair hearing officer reverses a decision to deny authorization of services, and the enrollee received the disputed services while the appeal was pending, the MCO or the PHP or the State must pay for those services, in accordance with State policy and regulations.