441—88.68 (249A) Review of contractor decisions and actions.
	 88.68(1) Clinical decision review. The contractor shall have written procedures by which enrollees and participating and nonparticipating providers may request a clinical decision review. The clinical decision review, when requested, shall be conducted by staff other than the person or persons who made the original clinical care decision. All policies related to clinical decision review shall be approved by the department prior to implementation. The contractor’s clinical decision review policies shall further:
	  a.   	 Require acknowledgment of the receipt of a request for a clinical decision review to the enrollee and to the provider if applicable within three working days.
	  b.   	 Allow for participation by the enrollee and the provider.
	  c.   	 Set time frames for resolution including emergency procedures which are appropriate to the nature of the clinical decision under review.
	  d.   	 Require that 95 percent of all clinical decision reviews be resolved within 14 days of receipt of all required documentation and that 100 percent of all clinical decision reviews be resolved within 90 days of the receipt of all required documentation.
	  e.   	 Ensure the participation of contractor staff with authority to require corrective action.
	  f.   	 Include at least one level of internal review.
	  g.   	 Ensure the confidentiality of the enrollee.
	 88.68(2) Appeal to department. Enrollees may appeal clinical care decisions in accordance with the appeal process available to all persons receiving Medicaid-funded services as set forth in 441—Chapter 7 if the enrollee is not satisfied with the final decision rendered by the contractor through the contractor’s clinical decision review process.
	 88.68(3) Review of nonclinical decisions. The contractor shall have available to all enrollees and other persons who do business with the contractor a process for the review of any complaints or grievances concerning nonclinical matters. All policies related to the review of nonclinical decisions shall be approved by the department prior to implementation. Policies regarding the process for the review of nonclinical decisions shall incorporate the following:
	  a.   	 Allow initiation both verbally and in writing.
	  b.   	 Require a review conducted by someone other than the person who made the original decision.
	  c.   	 Require written notice acknowledging the receipt of a complaint or grievance.
	  d.   	 Require resolution of 95 percent of all complaints or grievances within 14 days of the receipt of all required documentation and resolution of 100 percent within 90 days of the receipt of all required documentation.
	 88.68(4) Written record. All requests for review of contractor decisions and actions, including all informal or verbal complaints which must be referred or researched for resolution, shall be recorded in writing. A log shall be retained and made available at the request of the department. The log shall include progress notes and method of resolution to allow determination of compliance with subrules 88.68(1) and 88.68(3).
	 88.68(5) Information concerning procedures relating to the review of contractor decisions and actions. The contractor’s written procedures for the review of contractor decisions and actions shall be provided to each new enrollee, to participating providers in a provider manual, and to nonparticipating providers upon request.
	 88.68(6) Periodic reports to the department. The contractor shall make reports to the department summarizing the review of contractor decisions and actions and resolutions to the reviews at a frequency specified in the contract.