State Medicaid Managed Care Advisory Committee (SMMCAC) Complaints, Appeals, and Fair Hearings Subcommittee

Call to order, roll call, and introductions. The meeting was convened by Karl Serrao, MD, Chair. Members present: Janet Concha, Xavier Bañales, Tyra Hinton.  A quorum was present. This subcommittee focuses on more effectively leveraging complaints data to identify potential problems in the Medicaid program, opportunities for improved MCO contract oversight and increasing program transparency. Also focuses on appeals and fair hearings processes, including implementation of an independent external medical reviewer. Managed care organization (MCO) internal appeal requirements What is an adverse benefit determination? The denial or limited authorization of a member or provider requested services, including the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; The reduction, suspension, or termination of a previously authorized service; The denial in whole or in part of payment for service;