Section R9-34-214. Contractor Process for an Expedited Resolution of an Appeal

A.       A contractor shall establish and maintain a review process for an expedited appeal. The contractor shall conduct an expedited appeal if:

Title      Ch. 34                                                                              Administrative Code

Arizona Health Care Cost Containment System - Grievance System

1.       The contractor receives a request for an appeal from an enrollee and the contractor determines that taking the time for a standard resolution could seriously jeopardize the enrollee's life or health, or ability to attain, maintain, or regain maximum function;

2.        The contractor receives a request for an expedited appeal from an enrollee supported with documentation from the provider that taking the time for a standard resolution could seriously jeopardize the enrollee's life or health, or ability to attain, maintain, or regain maximum function; or

3.        The contractor receives a request for an expedited appeal directly from a provider, with the enrollee's written con­ sent, and the provider indicates that taking the time for a standard resolution could seriously jeopardize the enrollee's life or health, or ability to attain, maintain, or regain maximum function.

B.       The contractor shall ensure that punitive action is not taken against a provider who requests an expedited resolution or who supports an enrollee's appeal.

C.       Ifthe contractor denies a request for expedited resolution of an appeal from an enrollee, the contractor shall:

1.       Resolve the appeal within the time-frame in R9-34-213; and

2. Make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two calendar days with a written notice.

Historical Note

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