LAC 50:XXIII.1101. Participant Rights, Grievances, and Appeals

A. The PACE organization must have a formal written appeals process in accordance with 42 CFR 460.122, with specified timeframes for response, to address noncoverage or nonpayment of a service, and involuntary disenrollment. B. Additional appeal rights under Medicare or Medicaid are available to the participant if an adverse decision is made in the PACE organization appeal process, or if the participant is involuntarily disenrolled from the PACE program. A PACE organization must inform a participant in writing of additional appeal rights available under Medicare or Medicaid. C. Medicaid-eligible participants who appeal through Medicaid shall be heard by the Division of Administrative Law (DAL) within the timeframes applicable to processing Medicaid appeals except in cases where federal PACE requirements require a more expeditious decision. The PACE organization shall prepare the Summary of Evidence in preparation for the appeal.