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Medicaid Managed Care Appendix FEPSDT Timeline & Documentationfor Medicaid Managed Care AppealsMedicaid Managed Care enrollees have appeal rights with their Managed Care Organization(MCO). In addition to appeal rights with the MCOs, enrollees may also file a grievance. Agrievance is an expression of dissatisfaction about any matter other than an action. An“action” is the denial or limited authorization of a requested service, including the type orlevel of service, the reduction, suspension, or termination of a previously authorized service.If the enrollee is seeking reversal of a denial of a service, they should file an appeal, not agrievance.The grievance and appeals process differs from MCO to MCO; however, each MCO must meetcertain contractual guidelines regarding grievances and appeals. All Medicaid Managed Careenrollees are allowed 60 calendar days from the date on the MCO’s notice of action orinaction to file an appeal. Within that timeframe the enrollee or a representative acting ontheir behalf and with the enrollee’s written consent may file an appeal or the provider mayalso file an appeal on behalf of the enrollee, with the enrollee’s written consent. The appealmay be filed either orally or in writing. If the initial request is made orally and is not anexpedited appeal, it must be followed with a written confirmation within 15 days of thenotice from the MCO to send the written confirmation. All Medicaid Managed Care enrolleesare: provided a reasonable opportunity to present evidence, testimony, and arguments aboutfact or law, in person, as well as in writing regarding their appeal; notified of any deadlinesfor doing so; and provided an opportunity before and during the appeals process to examinethe case file and documents considered during the appeals process.The MCO must acknowledge receipt of each grievance and appeal in writing and provideenrollees with assistance with the appeals process as needed. Specific details regardingeach MCO’s grievance and appeal processes can be located in the MCO’s enrollee handbook.Support Coordinators are encouraged to familiarize themselves with the enrolleehandbooks for each MCO. Enrollee handbooks can be accessed OAppealTimeframe(includes 14dayextension)ExpeditedAppealTimeframeTimeframes for MCOs to Make an Appeal DecisionAetna Better AmeriHealthHealthy Blue LouisianaHealth -44 days30-44 days30-44 days30-44 days72 hours72 hours72 hours72 hoursUnitedHealthcare30-44 days72 hoursOnce the appeal rights with the MCO are completed, enrollees may request a state fairhearing with the Division of Administrative Law (DAL). See Appendix L. Enrollees mustcomplete the MCO appeals process before asking for a state fair hearing. A state fair hearingmust be requested within 120 days from the date of the MCO’s Notice of Adverse BenefitRevised 9.2.2020

Medicaid Managed Care Appendix FDetermination unless an extension is requested. A state fair hearing may be delayed at therequest of the claimant/appellant or authorized representative, but cannot be delayed formore than 30 days without good cause. Enrollees may request a state fair hearing by mail,phone, fax or online.The timeframes for the state fair hearing process are below:State Fair HearingTimeframeExpedited State FairHearing Timeframe120 days from the date of the MCO’s Noticeof Adverse Benefit Determination*An additional 30 days extension can berequested.3 working days (after the DAL received thecase file and documentation)EPSDT Support Coordinators will need to follow the guidelines outlined in Medicaid ManagedCare Appendix T-1 for both appeal processes for Chisholm Medicaid Managed Care enrollees.A list of Managed Care Organization contacts is located in Medicaid Managed Care AppendixA.Revised 9.2.2020

Medicaid Managed Care Appendix HOpting In and Disenrolling from Medicaid Managed Carefor Physical Health Services for Chisholm Class MembersChisholm class members are children up to age 21 who currently receive or are eligiblefor Medicaid, and who are on the Developmental Disabilities Request for ServicesRegistry (DD RFSR). Members included in the Chisholm class and Home andCommunity Based Services (HCBS) waivers participants are required to enroll in aManaged Care Organization for specialized behavioral health services and Non‐Emergency Medical Transportation (NEMT). Members included in the Chisholm classand HCBS waiver participants who do not have Medicare have the opportunity toproactively opt‐in for physical health services or they can choose to stay with LegacyMedicaid for their physical health services.To Voluntary Opt-in to Medicaid Managed Care for Physical Health Services:Members can call Medicaid Managed Care at 1-855-229-6848 or go online atwww.healthy.la.gov to enroll in a Managed Care Organization. Members have until the2nd to last business day of the month to enroll with Medicaid Managed Care for theeffective date to be the first of the following month. For example, if you call MedicaidManaged Care on April 8th, the effective date of enrollment for the Managed CareOrganization will be May 1st. If you call Medicaid Managed Care on April 30th, theeffective date of enrollment for the Managed Care Organization will be June 1st.Disenrolling from Medicaid Managed Care for Physical Health Services:Chisholm class members can return to Legacy Medicaid for their physical health servicesat any time effective the earliest possible month that the action can be administrativelytaken, but will have to stay enrolled in Medicaid Managed Care for their behavioralhealth services and for non-emergency medical transportation. Members can callMedicaid Managed Care at 1-855-229-6848 or go online at www.healthy.la.gov todisenroll from Medicaid Managed Care. Members have until the 2nd to last business dayof the month to disenroll with Medicaid Managed Care for the effective date to be thefirst of the following month. For example, if you call Medicaid Managed Care on April8th, the effective date of disenrollment from the Managed Care Organization will be May1st. If you call Medicaid Managed Care on April 30th, the effective date of disenrollmentfor the Managed Care Organization will be June 1st. Members who have previouslydisenrolled from Medicaid Managed Care may reenroll in Medicaid Managed Care onlyduring the annual open enrollment period effective the earliest possible month the actioncan be administratively taken.Revised 3.13.19

Medicaid Managed Care Appendix HEPSDT Targeted PopulationMedicaid Managed Care ComplaintsIf you have a complaint against your Managed Care Organization please contact the HealthyLouisiana Line at 1-855-229-6848 (TTY: 1-855-526-3346) or you can e-mail your complaint tohealthy@la.gov. Specific details regarding each MCO’s grievance process can be located in theMCO’s enrollee handbook. Enrollee handbooks can be accessed at:http://LDH.louisiana.gov/index.cfm/page/1212.If you have questions or complaints about your health plan or Primary Care Provider (PCP),contact your health plan’s customer service department.Health plans customer service department: Aetna Better Health 1-855-242-0802 TTY: 711Available 24 hours a day, 7 days a week Healthy Blue 1-844-521-6941 TTY: 711Available Monday – Friday, 7:00 a.m. - 7:00 p.m. AmeriHealth Caritas 1-888-756-0004 TTY: 1-866-428-7588Available 24 hours a day, 7 days a week. Louisiana Healthcare Connections 1-866-595-8133 TTY: 711Available Monday – Friday, 7:00 a.m. – 7:00 p.m. UnitedHealthcare Community 1-866-675-1607 TTY: 711Available Monday – Friday, 7:00 a.m. – 7:00 p.m.If you have questions or complaints about your dental plan or Primary Dental Provider (PDP),contact your dental plan’s customer service department. Find out how to contact your dentalplan on the Contacting your plan page.Dental plans customer service department:8.17.21 DentaQuest 1-800-685-0143 TTY: 1-800-466-7566Live agents are available from 7:00 a.m. - 7: p.m. with the IVR active 24 hours a day(no matter if it is a holiday). MCNA Dental 1-855-702-6262 TTY : 1-800-846-5277Available Monday - Friday, 7:00 a.m. – 7:00 p.m.

Medicaid Managed Care Appendix QReferral to Medicaid Managed Care Case ManagementEPSDT - Targeted PopulationDate:TO:( ) Amerihealth Caritas Louisiana( ) Aetna Better Health of Louisiana( ) Healthy Blue( ) Louisiana Healthcare Connections ( ) United HealthcareAttn: Chisholm Case ManagementCase Manager’s Name:FROM: Support Coordination AgencyFax #Support Coordinator’s Name:Provider #:Support RE: Provider:Provider #:Phone #:Address:City:State/Zip:Service Type (if DME be specific):Service Name:Amount/# of Hours of Service:Participant Name:( ) InitialMID#:( ) RenewalPhone#:Responsible Party:Address:City:State/Zip:This is to inform you that this individual is receiving EPSDT - Support Coordination Services and we are sending thisnotice to:1. Make a referral for the above noted service. Please have the enrollee’s case managerassist with arranging these services. Please make sure the provider of choice includesour Provider #, Agency Name and Address on the request for Prior Authorization (PA). Weare also requesting that the provider is informed to send us a copy of the PA requestpacket at the same time that it is sent to you for processing.2. The enrollee has asked that their schedule for the above service be changed as per theattached Typical Weekly Schedule form. If this presents a scheduling problem, pleasecontact the Support Coordinator so that we can all discuss this with the enrollee/family.3. This is a reminder that the above named enrollee’s PA for the above service expires on//and the renewal needs to be sent for continued services.4. The enrollee wants to choose a new provider.5. The enrollee has selected the new provider listed above. The previous provider was:6. I am unable to find a provider that is willing to submit a request for a PA.7. We have not received a notice of approval for the renewal approval and the previous PAexpired on/ / .8. The provider is not providing the amount of services as per the CPOC and as priorauthorized and we have been unable to resolve the issue.9. Other:Support Coordinator’s Signature4/7/15Revised 3.13.19Date

Medicaid Managed Care Appendix S-1Instructions for Referrals to LDH Medicaid PALfor Services Authorized by Medicaid Managed CareSC should make the initial contact to the appropriate MCO PAL orMedicaid Managed Care Case Manager located in MedicaidManaged Care Appendix A. Document your attempt on the MCOPAL / Medicaid Managed Care Case Management Contact form(Medicaid Managed Care Appendix S-1).SC should make a second contact to the appropriate MCO PALlocated in Medicaid Managed Care Appendix A. Document yourattempt on the MCO PAL / Medicaid Managed Care CaseManagement Contact form (Medicaid Managed Care Appendix S-1).SC should make a third contact to the appropriate MCO PAL locatedin Medicaid Managed Care Appendix A. Document your attempton the MCO PAL / Medicaid Managed Care Case ManagementContact form (Medicaid Managed Care Appendix S-1).NOTE: The Referral to Medicaid Managed Care Case Management (Medicaid Managed CareAppendix Q) should be sent prior to a referral being sent to the Medicaid PAL. SupportCoordinators may conduct both a phone/e-mail contact along with sending the form to theappropriate Managed Care Organization contact. Submission of the form alone will not beconsidered as one of the above contacts.If the support coordinator is unsuccessful in resolving the issue with the MCO PAL or Medicaid ManagedCare Case Manager then a Referral to the Medicaid PAL (Medicaid Managed Care Appendix S-2) should be sent. Notify the PAL if PA approval has not been received within 60 days of the Choice of Provider. Notify the PAL if the MCO has been unable to resolve the following issues within 10 days of the Referralto the Medicaid Managed Care Case Manager (MMCCM): unable to locate a willing provider, the PArenewal approval is not received, service is not provided in the amount in PA or service not delivered attimes according to PA.The Referral must include the completed MCO PAL / Medicaid Managed Care Case Management Contact form(Medicaid Managed Care Appendix S-2) as well as all logs, referral forms and e-mails related to resolving theissue with the MCO PAL.If the PAL referral is sent to LDH, for a MCO member, LDH will forward the referral to the MCO requestingnotification upon resolution.Revised 8.26.21

Medicaid Managed Care Appendix S-2Referral to Medicaid PAL for Medicaid Managed Care EnrolleeEPSDT - Targeted PopulationONLY FOR USE AFTER SUBMITTING AREFERRAL TO MEDICAID MANAGED CARE CASE MANAGEMENT (MMC APPENDIX Q)Medicaid Managed Care Program EnrolleeDate:TO: Medicaid Prior Authorization Liaison (PAL) ۰ P.O. Box 91030 ۰ Baton Rouge, LA ۰ 70821-9030Attn: Nancy SpillmanFax 225-389-2749Support Coordinator’s Name:FROM:Provider #:Support Coordinator’sPhone#:Fax#:Managed Care Organization:Medicaid Managed Care CaseManager:Phone #:RE: State Plan Provider:Provider #:Phone #:Address:City:State/Zip:Service Type (if DME be specific):Service Name:Amount/# of Hours of Service:Beneficiary Name:( ) InitialMID#:Responsible Party:Address:City:( ) RenewalPhone#:State/Zip:This is to inform you that this individual is receiving EPSDT - Support Coordination Services and we arehaving/had the following problem with the Healthy Louisiana Plan Provider identified above (only those requiringPA): (Check the following that apply.)1. We have not received an approval within 60 days from the Choice of Provider date.2. The beneficiary has been advised of their right to choose another provider and we arebeginning the process again.3. The beneficiary has been advised of their right to choose another provider but hasdecided to stay with the same provider and wait until the PA packet is submitted.4. The provider is not providing services at the times the beneficiary requested and wehave been unable to resolve the issue.5. We have not received a notice of approval for the renewal approval and the previousPA expired on// .6. The provider is not providing the amount of services as per the CPOC and as priorauthorized and we have been unable to resolve the issue.7. The MCO has been unable to locate a willing provider within 10 days of the Referral toMedicaid Managed Care Case Management.8. Other:I certify that I have attached Medicaid Managed Care Appendix S-3 with all tracking andservice logs, referral forms and emails to this form prior to submittal to the Medicaid PAL. Allattempts to resolve the issue with the MCO PAL have been exhausted.Support Coordinator’s SignatureRevised 9.20.21Date

Medicaid Managed Care Appendix S-3MCO PAL / Medicaid Managed Care Case Management Contact FormThis form must be completed and sent along with all referrals to the Medicaid PAL for services authorized byMedicaid Managed Care.Initial ContactDate:Type:Reason for contact:Email (attach copy)Phone# Contact Name:Referral Form (attach copy)Other (specify:)Results of contact: (Describe in detail the results of the contact i.e. services approved, no reply, pending)Second ContactDate:Type:Reason for contact:Email (attach copy)Phone# Contact Name:Referral Form (attach copy)Other (specify:)Results of contact: (Describe in detail the results of the contact i.e. services approved, no reply, pending)Revised 9.23.20

Medicaid Managed Care Appendix S-3Third ContactDate:Type:Reason for contact:Email (attach copy)Phone# Contact Name:Referral Form (attach copy)Other (specify:)Results of contact: (Describe in detail the results of the contact i.e. services approved, no reply, pending)I certify that I have attached all tracking and service logs, referral forms and e-mails relatedto resolving this issue with the MCO PAL. All attempts to resolve this matter with the MCOPAL were exhausted without success prior to submitting a referral to the Medicaid PAL.Support Coordinator Name:SC Agency:Date of Medicaid PAL Referral:Reason for Referral:Revised 9.23.20

Medicaid Managed Care Appendix T-1Medicaid Managed CareEPSDT Timeline & DocumentationParticipant ContactsSupport Coordination ReferralsCase MaintenanceWithin 3 working days:As NeededPhone contact or face-to-face visit for Intake(Document on EPSDT Service Log)Follow up on obtaining informationto submit or obtain approval of aPA request, determine servicestart date after PA notice received,assist with identified needs andproblems with providers(Document on EPSDT Service Log& PA Tracking Log as needed)Within 10 calendar days:Face-to-face in-home visit for Assessment(Document on EPSDT Service Log)Within 35 calendar days:See Medicaid Managed Care Appendix F for Appeals InfoWithin 4 calendar days from notice of denial fromthe Managed Care Organization:Explain appeal rights & offer assistance. Explain to the familythat the provider can request a peer to peer review.(Document on PA Tracking Log & EPSDT Service Log)20 days from date appeal request filed:Monthly ContactsComplete and submit an approvableCPOC to SRI(EPSDT Checklist)AppealsAssure implementation ofrequested services listed on theCPOC(Document on PA Tracking Logand EPSDT Service Log)Check on appeal status.(Document on PA Tracking Log & EPSDT Service Log)After the Medicaid Managed Care appeal is exhausted,Division of Administrative Law (DAL) State Fair Hearing(SFH)Within 4 calendar days from notice of Appeal Denialfrom the Managed Care Organization:Quarterly ContactsFace-to-face visit review CPOC,status of services & servi

CarterJonesJ@aetna.com Phone: 504-667-4507 Fax: 844-227-9205 Richard Born BornR@aetna.com Phone: 504-667-4580 Fax: 844-227-9205 Peggy McCurry MccurryP@aetna.com 504-667-4519 Fax: 844-277-9205 Rachel Weary Director of Integrated Healthcare Management rweary@amerihealthcaritasla.com Phone: 225-300-9198 Cell: 225-910-2538 Fax: 225-757-8629 Beth Rasch