37.89.131 MENTAL HEALTH SERVICES PLAN, MEMBER NOTICE, GRIEVANCE AND RECONSIDERATION AND RIGHTS

(1) The department or its designee must notify the member or the member's designated representative in writing of a decision denying eligibility or a request for services. The requirements of ARM 37.5.505 do not apply to the notice. The notice will state:

(a) the member's name and identifying information;

(b) a statement of the decision, including the specific services, dates, and other information necessary to identify the matter at issue;

(d) an explanation of how to request a grievance or reconsideration regarding the determination.

(2) If the department fails to provide notice or fails to timely provide notice or if a notice required by (1) fails to comply substantially with the requirements of (1), the remedy is the provision of a new notice which does comply substantially with (1) and a new opportunity to request a reconsideration regarding the decision specified in the notice. A failure to give adequate or timely notice under (1) does not entitle the member to an authorization for the services that were denied.

(3) A member has the right to any applicable grievance processes provided by the department's review designee referred to in ARM 37.89.118 and, following exhaustion of such grievance processes, an informal reconsideration as provided in ARM 37.5.311 regarding a denial or termination of plan eligibility, a denial of authorization or coverage of services, or a determination that a member is liable to the department as provided in ARM 37.82.207 based upon a misrepresentation or failure to provide notification of changes in income or family.

(4) The department or its designee may request additional supporting information or documentation from the member or the provider for purposes of a grievance or informal reconsideration.

(a) The department will consider the written materials submitted and the rationale for the decision. In its discretion, if the department finds that resolution of the issues would be aided, the department may contact persons involved in the case, interested agencies or mental health professionals and may request that the member, the member's representative, a mental health professional, a provider representative or other appropriate persons to appear in person or by telephone conference to discuss the case.

(b) The department must make a decision on the informal reconsideration and notify the member or the member's representative in writing of the decision.

(5) A member must request a grievance according to the requirements specified by the department's designee.

(6) A member must request an informal reconsideration within 30 days after receiving notice of the grievance decision. A member that does not timely request an informal reconsideration is deemed to have accepted the determination and is not entitled to any further notice or review opportunity.

(7) A member is not entitled to continuation of benefits under these rules, ARM 37.5.316 or 42 CFR, part 431, subpart E.

(8) A provider is not entitled to payment for services provided after the effective date of a denial of authorization.

(9) A member is entitled only to the processes specifically provided in this rule to contest an adverse decision by the department or its designee. A member is not entitled to any administrative review or hearing procedure under ARM 37.5.304, et seq., or other department rule, regarding a denial or termination of plan eligibility, a denial of authorization or coverage of services, or any other issue arising under the plan.

(10) A member is not entitled to any grievance, reconsideration, review, hearing or other appeal process with respect to changes in eligibility coverage or other plan benefits which result from generally applicable changes in eligibility requirements, coverage provisions, rates, imposition of limitations, or other changes.

History: 2-4-201, 53-2-201, 53-6-113, 53-6-706, 53-21-703, MCA; IMP, 2-4-201, 53-1-601, 53-2-201, 53-6-101, 53-6-113, 53-6-116, 53-6-706, 53-21-202, 53-21-701, 53-21-703, MCA; NEW, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1998 MAR p. 3307, Eff. 12/18/98; AMD, 1999 MAR p. 308, Eff. 2/12/99; AMD, 1999 MAR p. 355, Eff. 3/1/99; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2001 MAR p. 27; AMD, 2008 MAR p. 1988, Eff. 9/12/08; AMD, 2011 MAR p. 322, Eff. 3/11/11.