With the mandatory implementation of managed care for nursing home residents, a large part of our practice is devoted to successfully appealing improper denials and discontinuances. Now that new state-wide rules are being implemented that change how managed care appeals are handled, our clients need to be more vigilant than ever in order to maximize their managed care reimbursement.
Internal Appeals are Mandatory: As of April 1, 2018, an internal appeal must be completed before NYS will process a Fair Hearing request. This rule applies to both mainstream managed care (“MMC”) and managed long-term care (“MLTC”) plans.
Timing of Internal Appeals: The deadline for requesting an Internal Appeal is sixty (60) days from the date of the Initial Adverse Determination. When the plan has discontinued coverage, the Internal Appeal should always include a request for Aid to Continue so coverage remains in place during the appeal. An Internal Appeal that includes a request for Aid to Continue must be submitted within 10 days of the date of the notice discontinuing coverage or before the effective date of the discontinuance notice, whichever is later.
IMPORTANT: The facility may not request an Internal Appeal without being authorized to do so by the resident-member or the resident-member’s legal representative (e.g., power of attorney or guardian).
Fair Hearing Request: If the Internal Appeal is partially or fully denied in a Final Adverse Determination, a Fair Hearing request must be made within sixty (60) days of the date of the denial notice. If Aid to Continue was requested in the Internal Appeal, that request should be reiterated in the Fair Hearing request. We are available to assist if Aid to Continue was requested but not provided.
IMPORTANT: Significantly, under the new rules only someone authorized to do so by the resident-member or the resident-member’s legal representative may request the Fair Hearing. In the past, anyone could request a Fair Hearing, but only an authorized representative could appear at the hearing.
Practical Considerations: Since improper denials and discontinuances are more likely to be reversed at a Fair Hearing than on an Internal Appeal, and an Internal Appeal is a pre-requisite to a Fair Hearing, nursing homes must implement procedures that incorporate the submission of a timely Internal Appeal in every case. Also, once authorizations are required in order to request an Internal Appeal or Fair Hearing, it is more important than ever for facilities to ensure that Medicaid authorizations are signed by residents and/or their legal representatives (power of attorney or guardian) on admission or at recertification.
