Electronic Code of Federal Regulations

Amendment

42 CFR--PART 460

Amendment(s) published January 19, 2021, in 86 FR 6134

Effective Dates: Mar. 22, 2021

98. Section 460.122 is amended by—

a. Revising the introductory text and paragraphs (b) and (c)(1), (2), and (4);

b. Redesignating paragraphs (c)(5) and (6) as paragraphs (c)(6) and (7), respectively;

c. Adding a new paragraph (c)(5);

d. Revising paragraphs (d), (g) and (h);

The revisions and additions read as follows:

§460.122   PACE organization's appeals process.

For purposes of this section, an appeal is a participant's action taken with respect to the PACE organization's noncoverage of, or nonpayment for, a service including denials, reductions, or termination of services. A request to initiate, modify or continue a service must first be processed as a service determination request under §460.121 before the PACE organization can process an appeal under this section.

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(b) Notification of participants. Upon enrollment, at least annually thereafter, and whenever the interdisciplinary team denies a service determination request or request for payment, the PACE organization must give a participant written information on the appeals process.

(c) *  *  *

(1) Timely preparation and processing of a written denial of coverage or payment as provided in §§460.121(i) and (m).

(2) How a participant or their designated representative files an appeal, including procedures for accepting oral and written appeal requests.

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(4) Review of an appeal by an appropriate third party reviewer or committee. An appropriate third party reviewer or member of a review committee must be an individual who meets all of the following:

(i) Appropriately credentialed in the field(s) or discipline(s) related to the appeal.

(ii) An impartial third party who meets both of the following:

(A) Was not involved in the original action.

(B) Does not have a stake in the outcome of the appeal.

(5) The distribution of written or electronic materials to the third party reviewer or committee that, at a minimum, explain all of the following:

(i) Services must be provided in a manner consistent with the requirements in §§460.92 and 460.98.

(ii) The need to make decisions in a manner consistent with how determinations under section 1862(a)(1)(A) of the Act are made.

(iii) The rules in §460.90(a) that specify that certain limitations and conditions applicable to Medicare or Medicaid or both benefits do not apply.

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(d) Opportunity to submit evidence. A PACE organization must give all parties involved in the appeal a reasonable opportunity to present evidence related to the dispute, in person, as well as in writing.

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(g) Notification. A PACE organization must give all parties involved in the appeal appropriate written notification of the decision to approve or deny the appeal.

(1) Notice of a favorable decision. Notice of any favorable decision must explain the conditions of the approval in understandable language.

(2) Notice of partially or fully adverse decisions. (i) Notice of any denial must—

(A) State the specific reason(s) for the denial;

(B) Explain the reason(s) why the service would not improve or maintain the participant's overall health status;

(C) Inform the participant of his or her right to appeal the decision; and

(D) Describe the external appeal rights under §460.124.

(ii) At the same time the decision is made, the PACE organization must also notify the following:

(A) CMS.

(B) The State administering agency.

(h) Actions following a favorable decision. A PACE organization must furnish the disputed service as expeditiously as the participant's health condition requires if a determination is made in favor of the participant on appeal.

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