Section R9-34-210. Contractor General Requirements for Grievance or Appeal Process

A.       A contractor shall provide reasonable assistance to enrollees in completing forms and taking other procedural steps. Reason­ able assistance includes, but is not limited to, providing inter­ preter services and toll-free numbers that have adequate TTY/ TTD (teletypewriter/telecommunications device for the deaf, and text telephone) and interpreter capability.

B.       The contractor shall acknowledge receipt of each grievance orally or in writing. The contractor shall acknowledge receipt of each appeal in writing.

C. The contractor shall ensure that the individual who makes a decision on a grievance or an appeal was not involved in any previous level of review or decision-making.

D.       The contractor shall ensure that a health care professional who makes decisions on any of the following appeals or grievances has the appropriate clinical expertise in treating the enrollee's condition or disease:

1.       An appeal of a denial that is based on lack of medical necessity,

2.       A grievance regarding denial of expedited resolution of an appeal, or

3.        A grievance or appeal that involves clinical issues.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).