Grievance Procedure for Claims and Services

A grievance review is a procedure undertaken on the behalf of an enrollee regarding:

• The availability, delivery or quality of services.
• Claims payment, handling or reimbursement for services.
• Matters pertaining to the benefits of the plan.
• The request to change a previous determination.

When filing an appeal, you or your representative must comply with the grievance procedures established by the health plan under which you are covered unless your complaint is an administrative appeal. You also have the option of contacting the Missouri Department of Insurance, Financial Institutions & Professional Registration at any time.

Expedited Grievance Review Procedure
An expedited grievance review process is available where the time frame of the standard grievance procedures would seriously jeopardize the member’s life, health or ability to regain maximum function. A request for an expedited review may be submitted orally or in writing.

Required Notification Timeframes: The health plan must notify the member orally within 72 hours after receiving a request for an expedited review, and shall provide written confirmation of its decision covering an expedited review within three working days of providing notification of the determination.

First Level Grievance Review
The health plan must acknowledge receipt of the written grievance within ten working days. The health plan then conducts a complete investigation within 20 working days. If the health plan cannot complete its investigation of the appeal within 20 working days, it must notify the member and the investigation must be completed within 30 working days thereafter. The health plan is required to provide written notice to you of its decision within five working days (within 15 days to the person who submitted the appeal if not the member). If you or your representative disagree with the health plan’s decision, you have the right to file for a second level grievance review.

Second Level Grievance Review
The health plan must have an advisory panel review and respond to your grievance. The advisory panel is comprised of other health plan members, health plan representatives and, if it is an issue of medical care, clinical peers of the same specialty of the case being reviewed that were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance. However, if you or your representative disagree with the advisory panel’s final decision, you have the right to appeal to MCHCP’s Board of Trustees (see next section) and the Director of the Missouri Department of Insurance, Financial Institutions & Professional Registration.

For detailed information on filing an appeal with the Missouri Department of Insurance, Financial Institutions & Professional Registration, contact:

Missouri Department of Insurance, Financial Institutions & Professional Registration (DIFP)
Attn: Consumer Affairs
PO Box 690
Jefferson City, MO 65102

Or call: 800.726.7390

Appeals to the MCHCP Board of Trustees
To address appeals submitted to MCHCP, the Board may utilize an independent hearing officer, such as the Administrative Hearing Commission, to conduct a fact finding hearing, making proposed Findings of Fact and Conclusions of Law. The hearing is scheduled by MCHCP. The parties to the hearing shall be the insured and the applicable health care contractor. You and a representative from the plan involved are notified in writing of the date, time and location of the hearing. You and the plan representative have the right to appear at the hearing and/or submit written or oral evidence. The party appealing to the Board shall carry the burden of proof.

The independent hearing officer submits a summary of the evidence, along with a recommendation to the Board. Copies of the summary, findings, conclusions and recommendations are sent to all parties. The Board may choose to review the transcript of the hearing. The Board reviews the summary and issues a final decision on the matter. All parties are provided with a written copy of the Board’s final decision.

To file an appeal with MCHCP after exhausting the appeal process with your plan, submit to:

Attn: Appeal  - Health

Board of Trustees
Missouri Consolidated Health Care Plan
P.O. Box 104355
Jefferson City, MO 65110-4355