Sec.17a-453a-15. Provider claim for payment grievance process

(a) If a contracted provider's claim for payment is denied by the designated agent, the contracted provider may file a claim for payment grievance with the designated agent. Contracted providers may initiate a first-level claim for payment grievance to the designated agent not later than thirty (30) calendar days after the date of the denial decision. The first-level claim for payment grievance shall not include any right to an administrative hearing from either DMHAS or its designated agent.

(b) DMHAS or its designated agent shall notify the contracted provider in writing of its first- level claim for payment grievance decision not later than thirty (30) calendar days following the date of receipt of all information as determined necessary by DMHAS to render a decision.

(c) Contracted provider may initiate a second-level claim for payment grievance. The second-level claim for payment grievance shall be submitted in writing directly to DMHAS not later than seven (7) calendar days following the date of the first-level claim for payment grievance denial decision. The second-level claim for payment grievance shall be submitted in writing and accompanied by all information as determined necessary by DMHAS to render a decision on the second-level claim for payment grievance.

(d) DMHAS shall neither accept, nor review, a second-level claim for payment grievance that does not conform with the submission requirements as specified in this section, unless the designated agent has failed to respond to the contracted provider within the time frame as specified in this section.

(e) Any second-level claim for payment grievance decision issued by DMHAS shall be final and shall conclude the grievance process. The second-level claim for payment grievance shall not include any right to an administrative hearing from either DMHAS or its designated agent.

(Adopted effective December 7, 2009)