C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 438—MANAGED CARE › Subpart F—Grievance and Appeal System

42 C.F.R. § 438.410

Expedited resolution of appeals

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(a) General rule. Each MCO, PIHP, and PAHP must establish and maintain an expedited review process for appeals, when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(b) Punitive action. The MCO, PIHP, or PAHP must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee's appeal.

(c) Action following denial of a request for expedited resolution. If the MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it must—

(1) Transfer the appeal to the timeframe for standard resolution in accordance with § 438.408(b)(2).

(2) Follow the requirements in § 438.408(c)(2).

Notes of Decisions
Cited in 1 case, 2005–2005 · leading case: Grier v. Goetz, 402 F. Supp. 2d 876 (M.D. Tenn. 2005).
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Grier v. Goetz, 402 F. Supp. 2d 876 (M.D. Tenn. 2005). · cites it 2× “To begin with, the State, MCC or provider must decide whether an appeal meets the criteria for expedited resolution defined in 42 C.F.R. § 438.410 (a) as “taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain,…”
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