FAQ Directory: Utilization Management, Credentialing and Provider Network

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4.15.2017 UM 9B: Timeliness of the Appeal Process for Medicaid Under the new Medicaid Managed Care Final Rule, effective July 1, 2017, Medicaid organizations are required to have only one level of appeal. However, this may not be effective immediately for organizations with contracts prior to this date. How will NCQA evaluate Medicaid organizations coming through under the 2017 standards and guidelines?

Organizations with one level of appeal will be evaluated against the timeliness requirements specified in the current 2017 standard. Medicaid organizations that maintain a two-level appeal process will be evaluated under the 2016 standard requirements; these time frames apply:

  • For preservice first-level appeals: 30 calendar days.
  • For postservice first-level appeals: 60 calendar days.

UM_CR 2017