Review and Appeals Procedure

PURPOSE: This rule establishes the policy of the board of trustees in regard to review and appeals procedures for participation in, and coverage of, services under the Missouri Consolidated Health Care Plan. (1) Claims Submissions and Initial Benefit Determinations. (A) Members shall use the claims and administration procedures established by the vendor administering the particular service for which coverage, authorization, or payment is sought. (B) Medical and pharmacy service claims are divided into three (3) types: pre-service, post-service, and concurrent claims. 1. Pre-service claims are requests for approval that the plan or vendor requires a member to obtain before getting medical care or filling a prescription, such as prior authorization or a decision whether a treatment, procedure, or medication is medically necessary. A. Pre-service claims must be decided within a reasonable period of time appropriate to the medical circumstances, but no later than twenty (20) business days from the date the vendor receives the claim. The vendor may extend the time period up to an additional thirty (30) days if, for reasons beyond the vendor’s control, the decision cannot be made within the first twenty (20) days. The vendor must notify the member prior to the expiration of the first twenty- (20-) day period, explain the reason for the delay, and request any additional information. If more information is requested, the member has at least forty-five (45) days to provide the information to the vendor. The vendor then must decide the claim no later than thirty (30) days after the additional information is supplied or after the period of time allowed to supply it ends, whichever is first. B. Urgent care claims are a special type of pre-service claim that require a quicker decision because waiting the standard time could seriously jeopardize the member’s life, health, or ability to regain maximum function. A request for an urgent care claim may be submitted verbally or in writing and will be decided within seventy-two (72) hours. Written confirmation of the decision will be sent by the vendor within three (3) business days. 2. Post-service claims are all other claims for services including claims after medical or pharmacy services have been provided, such as requests for reimbursement or payment of the costs for the services provided. A. Post-service claims must be decided within a reasonable period of time, but not later than twenty (20) business days after the vendor receives the claim. If, because of reasons beyond the vendor’s control, more time is needed to review the claim, the vendor may extend the time period up to an additional thirty (30) days. The vendor must notify the member prior to the expiration of the first twenty- (20-) day period, explain the reason for the delay, and request any additional information. If more information is requested, the member has at least forty-five (45) days to provide the information to the vendor. The vendor then must decide the claim no later than thirty (30) days after the additional information is supplied or after the period of time allowed to supply it ends, whichever is first. 3. Concurrent claims are claims related to an ongoing course of previously approved treatment. If the plan or vendor has approved an ongoing course of treatment to be provided over a period of time or number of treatments, any reduction or termination of the course of treatment will be treated as a benefit denial. The plan or vendor will notify a member in writing prior to reducing or ending a previously approved course of treatment in sufficient time to allow the member, or the member’s provider, to appeal and obtain a determination before the benefit is reduced or terminated. (C) Claims incurred should be furnished to the vendor by the provider or the member as soon as reasonably possible. Claims filed more than one (1) year after charges are incurred will not be honored. All claims are reviewed and/or investigated by the vendor before they are paid. (D) If a member, a provider, or authorized representative on behalf of a member, submits a request for coverage or a claim for services that is denied in whole or in part, the member will receive an initial denial notice within the time frames described in this rule that will include the following information: 1. The reasons for the denial; 2. Reference to the plan provision, regulation, statute, clinical criteria, or guideline on which the denial was based, with information as to how the member can obtain a copy of the provision, regulation, statute, clinical criteria, or guideline free of charge; 3. A description of any documentation or information that is necessary for the member to provide if documentation or information is missing and an explanation as to why the documentation or information is needed, if applicable; and 4. Information as to steps the member can take to submit an appeal of the denial. (2) General Appeal Provisions. (A) All individuals seeking review or appeal of a decision of the plan, plan administrator, claims administrator, or any vendor shall follow the procedures applicable to the type of decision appealed as set forth in this rule. (B) All appeals must be submitted in writing to the appropriate reviewer as established in this rule by the member, the individual seeking review, or his/her authorized representative. (C) Unless specifically provided otherwise in this rule, all appeals to the plan, plan administrator, claims administrator, or applicable vendor must be made, initiated in writing, within one hundred eighty (180) days of issuance of the denial or notice which gave rise to the appeal. (3) Appeal Process for Medical and Pharmacy Determinations. (A) Definitions. Notwithstanding any other rule in this chapter to the contrary, for purposes of a member’s right to appeal any adverse benefit determination made by the plan, the plan administrator, a claims administrator, or a medical or pharmacy benefit vendor, relating to the provision of health care benefits, other than those provided in connection with the plan’s dental or vision benefit offering, the following definitions apply: 1. Adverse benefit determination. An adverse benefit determination means any of the following: A. A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit, including any denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility to participate in the plan; B. A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate; or C. Any rescission of coverage after an individual has been covered under the plan; 2. Appeal (or internal appeal). An appeal or internal appeal means review by the plan, the plan administrator, a claims administrator, or a medical or pharmacy benefit vendor of an adverse benefit determination; 3. Claimant. Claimant means an individual who makes a claim under this subsection. For purposes of this subsection, references to claimant include a claimant’s authorized representative; 4. External review. The United States Department of Health and Human Services (HHS) conducts external reviews for adverse benefit determinations regarding medical and pharmacy benefits administered by Anthem and Express Scripts, Inc. that involve medical judgment (including, but not limited to, those based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or a determination that a treatment is experimental or investigational) and a rescission of coverage (regardless of whether or not the rescission has any effect on any particular benefit at that time); 5. Final internal adverse benefit determination. A final internal adverse benefit determination means an adverse benefit determination that has been upheld by the plan, the plan administrator, a claims administrator, or a medical or pharmacy benefit vendor at the completion of the internal appeals process under this subsection, or an adverse benefit determination with respect to which the internal appeals process has been deemed exhausted by application of applicable state or federal law; 6. Final external review decision. A final external review decision means a determination rendered under the external review process at the conclusion of an external review; and 7. Rescission. A rescission means a termination or discontinuance of medical or pharmacy coverage that has retroactive effect, except that a termination or discontinuance of coverage is not a rescission if— A. The termination or discontinuance of coverage has only a prospective effect; or B. The termination or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage. (B) Internal Appeals. 1. Eligibility, termination for failure to pay, or rescission. Adverse benefit determinations denying or terminating an individual’s coverage under the plan based on a determination of the individual’s eligibility to participate in the plan or the failure to pay premiums or any rescission of coverage based on fraud or intentional misrepresentation of a member or authorized representative of a member are appealable exclusively to the Missouri Consolidated Health Care Plan (MCHCP) Board of Trustees (board). A. The internal review process for appeals relating to eligibility, termination for failure to pay, or rescission shall consist of one (1) level of review by the board. B. Adverse benefit determination appeals to the board must identify the eligibility, termination, or rescission decision being appealed and the reason the claimant believes the MCHCP staff decision should be overturned. The member should include with his/her appeal any information or documentation to support his/her appeal request. C. The appeal will be reviewed by the board in a meeting closed pursuant to section 610.021, RSMo, and the appeal will be responded to in writing to the claimant within sixty (60) days from the date the board received the written appeal. D. Determinations made by the board constitute final internal adverse benefit determinations and are not eligible for external review, except as specifically provided in 22 CSR 10-3.075(4)(A)4. 2. Medical and pharmacy services. Members may request internal review of any adverse benefit determination relating to urgent care, pre-service claims, and post-service claims made by the plan’s medical and pharmacy vendors. A. Appeals of adverse benefit determinations shall be submitted in writing to the vendor that issued the original determination giving rise to the appeal at the applicable address set forth in this rule. B. The internal review process for adverse benefit determinations relating to medical services consists of two (2) levels of internal review provided by the medical vendor that issued the adverse benefit determination. (I) First level appeals must identify the decision being appealed and the reason the member believes the original claim decision should be overturned. The member should include with his/her appeal any additional information or documentation to support the reason the original claim decision should be overturned. (II) First level appeals will be reviewed by the vendor by someone who was not involved in the original decision and will consult with a qualified medical professional if a medical judgment is involved. First level medical appeals will be decided within twenty (20) business days from the date the vendor received the first level appeal request. (a) If, because of reasons beyond the vendor’s control, more time is needed to review the appeal, the vendor may extend the time period up to an additional thirty (30) days. The vendor must notify the member prior to the expiration of the first twenty- (20-) day period, explain the reason for the delay, and request any additional information. If more information is requested, the member has at least forty-five (45) days to provide the information to the vendor. The vendor then must decide the claim no later than thirty (30) days after the additional information is supplied or after the period of time allowed to supply it ends, whichever is first. Written confirmation of the decision will be sent by the vendor within fifteen (15) business days. (III) An expedited appeal of an adverse benefit determination may be requested when a decision is related to a pre-service claim for urgent care. Expedited appeals will be reviewed by the vendor by someone who was not involved in the original decision and will consult with a qualified medical professional if a medical judgment is involved. Expedited appeals will be responded to within seventy-two (72) hours after receiving a request for an expedited review with written confirmation of the decision to the member within three (3) business days of providing notification of the determination. (IV) Second level appeals must be submitted in writing within sixty (60) days of the date of the first level appeal decision letter that upholds the original adverse benefit determination. Second level appeals should include any additional information or documentation to support the reason the member believes the first level appeal decision should be overturned. Second level appeals will be reviewed by the vendor by someone who was not involved in the original decision or first level appeal and will include consultation with a qualified medical professional if a medical judgment is involved. Second level medical appeals will be decided within twenty (20) days for post-service claims and within fifteen (15) days for pre-service claims from the date the vendor received the second level appeal request. (a) If, because of reasons beyond the vendor’s control, more time is needed to review the appeal, the vendor may extend the time period up to an additional thirty (30) days. The vendor must notify the member prior to the expiration of the first twenty- (20-) day period, explain the reason for the delay, and request any additional information. If more information is requested, the member has at least forty-five (45) days to provide the information to the vendor. The vendor then must decide the claim no later than thirty (30) days after the additional information is supplied or after the period of time allowed to supply it ends, whichever is first. Written confirmation of the decision will be sent by the vendor within fifteen (15) business days. (V) For members with medical coverage through Anthem— (a) First and second level pre-service, first and second level post-service, and concurrent claim appeals must be submitted in writing to— Anthem Blue Cross and Blue Shield Attn: Grievance Department PO Box 105568 Atlanta, Georgia 30348-5568 or by fax to (888) 859-3046. (b) Expedited appeals may be submitted by calling (844) 516-0248 or by submitting a written fax to (800) 368-3238. C. The internal review process for adverse benefit determinations relating to pharmacy and the Pharmacy Lock-In Program consists of one (1) level of internal review provided by the pharmacy vendor. (I) Pharmacy appeals. Pharmacy appeals and Pharmacy Lock-In Program appeals must identify the matter being appealed and should include the member’s (and dependent’s, if applicable) name, the date the member attempted to fill the prescription, the prescribing physician’s name, the drug name and quantity, the cost of the prescription, if applicable, and any applicable reason(s) relevant to the appeal including the reason(s) the member believes the claim should be paid, the reason(s) the member believes s/he should not be included in the Pharmacy Lock-In Program, and any other written documentation to support the member’s belief that the original decision should be overturned. (II) All pharmacy appeals must be submitted in writing to— Express Scripts Attn: Clinical Appeals Department PO Box 66588 St. Louis, MO 63116-6588 or by fax to (877) 852-4070. (III) All Pharmacy Lock-In Program appeals must be submitted in writing to— Express Scripts Drug Utilization Review Program Mail Stop HQ3W03 One Express Way St. Louis, MO 63121. (IV) Pharmacy appeals will be reviewed by someone who was not involved in the original decision and the reviewer will consult with a qualified medical professional if a medical judgment is involved. Pharmacy appeals will be responded to in writing to the member within sixty (60) days for post-service claims and thirty (30) days for pre-service claims from the date the vendor received the appeal request. (V) The Pharmacy Benefit Manager will respond to Pharmacy Lock-In Program appeals in writing to the member within thirty (30) days from the date the Pharmacy Benefit Manager received the appeal request. D. Members may seek external review only after they have exhausted all applicable levels of internal review or received a final internal adverse benefit determination. (I) A claimant or authorized representative may file a written request for an external review within four (4) months after the date of receipt of a final internal adverse benefit determination. (II) The claimant can submit an external review request in writing to— MAXIMUS Federal Services State Appeals East 3750 Monroe Ave., Suite 708 Pittsford, NY 14534 or by fax to (888) 866-6190 or to request a review online at externalappeal.cms.gov. (III) The claimant may call the toll-free number (888) 975-1080 with any questions or concerns during the external review process and can submit additional written comments to the external reviewer at the mailing address above. (IV) The external review decision will be made as expeditiously as possible and within forty-five (45) days after receipt of the request for the external review. (V) A claimant may make a written or oral request for an expedited external review if the adverse benefit determination involves a medical condition of the claimant for which the time frame for completion of a standard external review would seriously jeopardize the life or health of the claimant; or would jeopardize the claimant’s ability to regain maximum function; or if the final internal adverse benefit determination involves an admission, availability of care, continued stay, or health care item or service for which the claimant received services, but has not been discharged from a facility. 3. For all internal appeals of adverse benefit determinations, the plan or the vendor reviewing the appeal will provide the member, free of charge, with any new or additional evidence or rationale considered, relied upon, or generated by the plan or the vendor in connection with reviewing the claim or the appeal and will give the member an opportunity to respond to such new evidence or rationale before issuing a final internal adverse determination. (4) Except as otherwise expressly provided in this rule, appeals of adverse determinations made by MCHCP may be appealed to the board by sending or uploading the written appeal to one (1) of the following: Attn: Appeal Board of Trustees Missouri Consolidated Health Care Plan PO Box 104355 Jefferson City, MO 65110 or by fax to (866) 346-8785 or online at www.mchcp.org (5) In reviewing appeals, notwithstanding any other rule, the board and/or staff may grant any appeals when there is credible evidence to support approval under the following guidelines: (A) If a subscriber currently has coverage under the plan, MCHCP may approve the subscriber’s request to enroll his/ her newborn retroactively to the date of birth if the appeal is received within three (3) months of the child’s birth date. Valid proof of eligibility must be included with the appeal; (B) MCHCP may approve a subscriber’s appeal and not hold the subscriber responsible when there is credible evidence that there has been an error or miscommunication through the subscriber’s payroll/personnel office, MCHCP, or MCHCP vendor that was no fault of the subscriber; (C) MCHCP may approve an appeal to change the type of medical or vision plan that the subscriber elected or defaulted to during the annual open enrollment period if the request is made within thirty-one (31) calendar days of the beginning of the new plan year, except that no changes will be considered for Health Savings Account (HSA) Plan elections after the first MCHCP Health Savings Account contribution has been transmitted for deposit to the subscriber’s account. This guideline may not be used to elect or cancel coverage or to enroll or cancel dependents. If a subscriber has his/her premium collected pre-tax by qualified payroll deduction through a cafeteria plan, changes may be approved if the reason given is allowed by the cafeteria plan; (D) MCHCP may allow one (1) reinstatement for termination due to non-payment per lifetime of account. Payment in full for all past and current premiums due for reinstatement must be included with the appeal. MCHCP may allow one (1) additional reinstatement if the subscriber submits an automatic withdrawal authorization; (E) MCHCP may approve a subscriber’s appeal to terminate dental and/or vision coverage if the appeal is received within thirty-one (31) calendar days of the beginning of the new plan year and if no claims have been made or paid during the new plan year. If a subscriber has his/her premium collected pretax by qualified payroll deduction through a cafeteria plan, termination may be approved if the reason given is allowed by a cafeteria plan; (F) MCHCP may approve an appeal regarding late receipt of proof-of-eligibility documentation if the subscriber can provide substantiating evidence that it took an unreasonable amount of time for the government agency creating the documentation to provide subscriber with requested documentation; (G) MCHCP may approve a subscriber’s appeal to enroll after a deadline due to late notice of loss of coverage from subscriber’s previous carrier if the appeal is within sixty (60) days from date of late notice; (H) MCHCP may approve appeals, other than those relating to non-payment, if subscriber is able to provide substantiating evidence that requisite information was sent during eligibility period; (I) MCHCP may approve an appeal regarding plan changes retrospectively for subscribers who are new employees within thirty (30) days of election of coverage if no claims have been filed with the previous carrier. If a subscriber has his/ her premium collected pre-tax by qualified payroll deduction through a cafeteria plan, changes may be approved if the reason given is allowed by the cafeteria plan; and (J) Once every five (5) years per account, MCHCP may approve an appeal where a subscriber missed a deadline. MCHCP may only approve an appeal under this guideline if the appeal is received within sixty (60) days of the missed deadline. This guideline may not be used to approve an appeal of a voluntary cancellation or an appeal of a deadline that is statutorily mandated. AUTHORITY: section 103.059, RSMo 2016.* Emergency rule filed Dec. 20, 2004, effective Jan. 1, 2005, expired June 29, 2005. Original rule filed Dec. 20, 2004, effective June 30, 2005. Emergency amendment filed Dec. 22, 2008, effective Jan. 1, 2009, expired June 29, 2009. Amended: Filed Dec. 22, 2008, effective June 30, 2009. Amended: Filed Feb. 17, 2010, effective Aug. 30, 2010. Emergency amendment filed Dec. 22, 2010, effective Jan. 1, 2011, terminated Jan. 20, 2011. Emergency amendment filed Jan. 10, 2011, effective Jan. 20, 2011, expired June 29, 2011. Amended: Filed Jan. 10, 2011, effective June 30, 2011. Emergency amendment filed Nov. 1, 2011, effective Jan. 1, 2012, expired June 28, 2012. Amended: Filed Nov. 1, 2011, effective May 30, 2012. Emergency amendment filed Oct. 30, 2012, effective Jan. 1, 2013, expired June 29, 2013. Amended: Filed Oct. 30, 2012, effective May 30, 2013. Emergency amendment filed Oct. 30, 2013, effective Jan. 1, 2014, expired June 29, 2014. Amended: Filed Oct. 30, 2013, effective June 30, 2014. Emergency amendment filed Oct. 29, 2014, effective Jan. 1, 2015, terminated May 30, 2015. Amended: Filed Oct. 29, 2014, effective May 30, 2015. Emergency amendment filed Oct. 28, 2015, effective Jan. 1, 2016, expired June 28, 2016. Amended: Filed Oct. 28, 2015, effective May 30, 2016. Emergency amendment filed Oct. 30, 2019, effective Jan. 1, 2020, expired June 28, 2020. Amended: Filed Oct. 30, 2019, effective May 30, 2020. Emergency amendment filed Oct. 27, 2023, effective Jan. 1, 2024, expired June 28, 2024. Amended: Filed Oct. 27, 2023, effective May 30, 2024. Emergency amendment filed Oct. 25, 2024, effective Jan. 1, 2025, expired June 29, 2025. Amended: Filed Oct. 25, 2024, effective May 30, 2025. Emergency amendment filed Nov. 12, 2025, effective Jan. 1, 2026, expired June 29, 2026. Amended: Filed Nov. 12, 2025, effective May 30, 2026. *Original authority: 103.059, RSMo 1992.