North Carolina § 108D-11 - Managed care entity grievance and appeal procedures, generally.

§ 108D-11. Managed care entity grievance and appeal procedures, generally.

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. An enrollee, or the enrollee's authorized representative, may file grievances and managed care entity level appeals orally or in writing. A managed care entity shall not attempt to influence, limit, or interfere with an enrollee's right or decision to file a grievance, request for a managed care entity level appeal, or a contested case hearing. However, nothing in this Chapter shall be construed to prevent a managed care entity from doing any of the following: Offering an enrollee alternative services. Engaging in clinical or educational discussions with enrollees or providers. Engaging in informal attempts to resolve enrollee concerns prior to the issuance of a notice of grievance disposition or notice of resolution. A managed care entity shall not take punitive action against a provider for any of the following: Filing a grievance on behalf of an enrollee or supporting an enrollee's grievance. Requesting a managed care entity level appeal on behalf of an enrollee or supporting an enrollee's request for a managed care entity level appeal. Requesting an expedited managed care entity level appeal on behalf of an enrollee or supporting an enrollee's request for a managed care entity level expedited appeal. Requesting a contested case hearing on behalf of an enrollee or supporting an enrollee's request for a contested case hearing. The appeal procedures set forth in this Article shall not apply to instances in which the sole basis for the managed care entity's decision is a provision in the State Plan or in federal or State law requiring an automatic change adversely affecting some or all beneficiaries. History (2013-397, s. 1; 2019-81, s. 1(a); 2021-62, s. 2.1(f).) Editor's Note. - Session Laws 2013-397, s. 1, enacted this Article as G.S. 108D-4 through 108D-9. It was renumbered as G.S. 108D-11 through 108D-16 at the direction of the Revisor of Statutes. This section was enacted as G.S. 108D-4. It has been renumbered as G.S. 108D-11 at the direction of the Revisor of Statutes. Session Laws 2015-241, s. 12H.3(a), (b), provides: "(a) The Department of Health and Human Services (Department) shall ensure that local management entities/managed care organizations (LME/MCOs) utilize an out-of-network agreement that contains standardized elements developed in consultation with LME/MCOs. The out-of-network agreement shall be a streamlined agreement between a single provider of behavioral health or intellectual/developmental disability (IDD) services and an LME/MCO to ensure access to care in accordance with 42 C.F.R. § 438.206(b)(4), reduce administrative burden on the provider, and comply with all requirements of State and federal laws and regulations. Beginning November 1, 2015, LME/MCOs shall use the out-of-network agreement in lieu of a comprehensive provider contract when all of the following conditions are met: "(1) The services requested are medically necessary and cannot be provided by an in-network provider. "(2) The behavioral health or IDD provider's site of service delivery is located outside of the geographical catchment area of the LME/MCO, and the LME/MCO is not accepting applications or the provider does not wish to apply for membership in the LME/MCO closed network. "(3) The behavioral health or IDD provider is not excluded from participation in the Medicaid program, the NC Health Choice program, or other State or federal health care program. "(4) The behavioral health or IDD provider is serving no more than two enrollees of the LME/MCO, unless the agreement is for inpatient hospitalization, in which case the LME/MCO may, but shall not be required to, enter into more than five such out-of-network agreements with a single hospital or health system in any 12-month period. "(b) Medicaid providers providing services pursuant to an out-of-network agreement shall be considered a network provider for purposes of Chapter 108D of the General Statutes only as it relates to enrollee grievances and appeals." Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'" Session Laws 2015-241, s. 33.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2015-2017 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2015-2017 fiscal biennium." Session Laws 2015-241, s. 33.6, is a severability clause. Session Laws 2017-57, s. 11H.8(a), (b), provides: "(a) The Department of Health and Human Services (Department) shall continue to ensure that local management entities/managed care organizations (LME/MCOs) utilize an out-of-network agreement that contains standardized elements developed in consultation with LME/MCOs. The out-of-network agreement shall be a streamlined agreement between a single provider of behavioral health or intellectual/developmental disability (IDD) services and an LME/MCO to ensure access to care in accordance with 42 C.F.R. § 438.206(b)(4), reduce administrative burden on the provider, and comply with all requirements of State and federal laws and regulations. LME/MCOs shall use the out-of-network agreement in lieu of a comprehensive provider contract when all of the following conditions are met: "(1) The services requested are medically necessary and cannot be provided by an in-network provider. "(2) The behavioral health or IDD provider's site of service delivery is located outside of the geographical catchment area of the LME/MCO, and the LME/MCO is not accepting applications or the provider does not wish to apply for membership in the LME/MCO closed network. "(3) The behavioral health or IDD provider is not excluded from participation in the Medicaid program, the NC Health Choice program, or other State or federal health care program. "(4) The behavioral health or IDD provider is serving no more than two enrollees of the LME/MCO, unless the agreement is for inpatient hospitalization, in which case the LME/MCO may, but shall not be required to, enter into more than five such out-of-network agreements with a single hospital or health system in any 12-month period. "(b) Medicaid providers providing services pursuant to an out-of-network agreement shall be considered a network provider for purposes of Chapter 108D of the General Statutes only as it relates to enrollee grievances and appeals." Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'" Session Laws 2017-57, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2017-2019 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2017-2019 fiscal biennium." Session Laws 2017-57, s. 39.6, is a severability clause. Session Laws 2019-81, s. 1(b), provides: "This section is effective October 1, 2019, and applies to (i) appeals arising from local management entity/managed care organization (LME/MCO) notices of adverse benefit determination mailed on or after that date and (ii) grievances received by an LME/MCO on or after that date." Session Laws 2021-62, s. 2.1(i), made the deletion of the former second sentence of subsection (b) of this section by Session Laws 2021-62, s. 2.1(f), effective June 29, 2021, and applicable to (i) appeal request forms under G.S. 108A-70.9A(e), 108D-5.7(a), and 108D-15(f) issued on or after that date and (ii) appeals requested on or after that date. Effect of Amendments. - Session Laws 2019-81, s. 1(a), effective October 1, 2019, rewrote the section. For effective date and applicability, see Editor's note. Session Laws 2021-62, s. 2.1(f), deleted the former second sentence of subsection (b), which read: "However, unless the enrollee, or the enrollee's authorized representative, requests an expedited appeal, the oral appeal must be followed by a written, signed appeal." For effective date and applicability, see editor's note.