FAQ Directory: Long-Term Services and Supports Distinction for Health Plans

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8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?

NCQA allows any individual at the organization to overturn a denial on appeal. Upheld denials still require same-or-similar specialist review for medical necessity decisions and review by a nonsubordinate for benefit decisions.

This applies to the following Programs and Years:
HP 2017, 2018|MBHO 2017|UM-CR-PN 2018