Time Limits for Resolving Internal Appeals

(A) MCOs, Accountable Care Partnership Plans, SCO Plans, One Care Plans, and the behavioral health contractor must resolve standard internal appeals within 30 days after receiving the appeal, including any extensions pursuant to 130 CMR 508.012(C). (B) Where the provider requests an expedited appeal or the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor determines (for a request from the member) that following the standard time frame could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function, the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or the behavioral health contractor must resolve the internal appeal on an expedited basis within 72 hours after receiving the appeal, unless the time frames are extended by up to 14 days pursuant to 130 CMR 508.012(C), in which event the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor must resolve the appeal within 17 days after receiving the appeal. If the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor denies a member’s request for expedited resolution of an internal appeal, the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor must resolve the appeal in accordance with the time frames in 130 CMR 508.012(A) and must make reasonable efforts to give the member prompt, oral notice of the denial and follow up within two calendar days with a written notice. The MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor cannot deny a provider’s request (on the member’s behalf) that an internal appeal be expedited. (C) MCOs, Accountable Care Partnership Plans, SCO Plans, One Care Plans, and the behavioral health contractor may extend the time frame for resolving internal appeals under the following circumstances, provided that, if the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or the behavioral health contractor extends the time frame, it must give the member written notice of the reason for the extension: (1) the member requested the extension; (2) the MCO, Accountable Care Partnership Plan, SCO Plan or the behavioral health contractor showed (to the MassHealth agency’s satisfaction) that there is a need for additional information and how the extension is in the member’s interest; or (3) the One Care Plan showed (to the satisfaction of the MassHealth agency and the Centers for Medicare & Medicaid Services (CMS)) that there is a need for additional information and how the extension is in the member’s interest.