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Providers Filing Appeals on Enrollees' Behalf

On May 6, 2016, The Centers for Medicare & Medicaid Services (CMS) issued the Medicaid Final Rule to modernize Medicaid managed care and ensure appropriate beneficiary protections. One aspect of this Rule is that it reemphasizes that providers are required to obtain an enrollee’s written consent before acting on the enrollee’s behalf in requesting an appeal such as a pre-service appeal.

In accordance with the Final Rule, effective with appeals requests submitted 3/1/2017 and after, providers filing appeals on an enrollee’s behalf will be required to submit proof of written consent before the plan can address and resolve the appeal.

Providers may continue to request appeals regarding the denial of claim payment on their own behalf.

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Last Updated On: 12/3/2020