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. § 438.424

Effectuation of reversed appeal resolutions

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(a) Services not furnished while the appeal is pending. If the MCO, PIHP, or PAHP, or the State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination.

(b) Services furnished while the appeal is pending. If the MCO, PIHP, or PAHP, or the State fair hearing officer reverses a decision to deny authorization of services, and the enrollee received the disputed services while the appeal was pending, the MCO, PIHP, or PAHP, or the State must pay for those services, in accordance with State policy and regulations.

Notes of Decisions
Cited in 4 cases (4 in the last 5 years), 2022–2023 · leading case: Forloine v. Persily
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Kevin Wiesner v. Washtenaw County Community Mental Health (2022) michctapp “That is, 42 CFR 438.424(a) provides that if the state fair hearing officer reversed a managed care organization’s or PIHP’s decision to deny, limit, or delay services that were not furnished while the appeal was pending, that entity “must authorize or provide the disputed…”
Kevin Wiesner v. Washtenaw County Community Mental Health (2022) michctapp “That is, 42 CFR 438.424(a) provides that if the state fair hearing officer reversed a managed care organization’s or PIHP’s decision to deny, limit, or delay services that were not furnished while the appeal was pending, that entity “must authorize or provide the disputed…”
Forloine v. Persily (2023) wvsd “Under 42 C.F.R. § 438.424 (a), if a fair hearing officer reverses a decision denying services that were not furnished while the appeal was pending, the MCO “must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires…”
Forloine v. Persily (2023) wvsd “Under 42 C.F.R. § 438.424 (a), if a fair hearing officer reverses a decision denying services that were not furnished while the appeal was pending, the MCO “must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires…”
— 42 C.F.R. § 438.424(a) — 2 cases
Kevin Wiesner v. Washtenaw County Community Mental Health (2022) michctapp “That is, 42 CFR 438.424(a) provides that if the state fair hearing officer reversed a managed care organization’s or PIHP’s decision to deny, limit, or delay services that were not furnished while the appeal was pending, that entity “must authorize or provide the disputed…”
Kevin Wiesner v. Washtenaw County Community Mental Health (2022) michctapp “That is, 42 CFR 438.424(a) provides that if the state fair hearing officer reversed a managed care organization’s or PIHP’s decision to deny, limit, or delay services that were not furnished while the appeal was pending, that entity “must authorize or provide the disputed…”
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