LAC 50:I.3703. Definitions

Adverse Benefit Determination—any of the following: 1. the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; 2. the reduction, suspension, or termination of a previously authorized service; 3. the denial, in whole or in part, of payment for a service; 4. the failure to provide services in a timely manner, as defined by the state; 5. the failure of an MCO to act within the timeframes provided in 42 CFR §438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals; 6. the denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductible, coinsurance, and other member financial liabilities. Appeal—a request for review of an adverse benefit determination as defined in this Section. Grievance—an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to: 1. the quality of care or services provided; 2. aspects of interpersonal relationships, such as rudeness of a provider or employee; 3. failure to respect the member’s rights regardless of whether remedial action is requested; or 4. the member’s rights to dispute an extension of time proposed by the MCO to make an authorization decision.