42 CFR 438 Subpart F
The federal floor for Medicaid managed care appeals. Beneficiaries get internal plan appeal + State Fair Hearing rights, with expedited timelines for urgent care.
What 42 CFR 438 Subpart F does
42 CFR Part 438 Subpart F requires every Medicaid managed care plan (MCO, PIHP, PAHP) to maintain a grievance and appeal system that gives enrollees (1) a right to file a grievance about any complaint not related to a coverage decision, (2) an internal plan appeal of any adverse benefit determination, and (3) the right to a State Fair Hearing AFTER exhausting internal appeal. States may add to the federal floor but cannot subtract. Expedited timelines: 72 hours when standard timeframes would seriously jeopardise the enrollee's life or health.
When to invoke it
Cite 42 CFR 438 Subpart F on every Medicaid managed care denial. Note that Medicaid enrollees often have RIGHT TO CONTINUE BENEFITS during appeal (§438.420) — services that were previously authorised must continue at the previous level until the appeal is resolved, if the enrollee requests it within 10 days of notice. This is unique to Medicaid and very powerful when prior auth is being pulled mid-treatment.
Key deadlines and thresholds
| Requirement | Deadline / threshold |
|---|---|
| Time to file internal appeal | 60 days from notice of action |
| Standard plan appeal decision | 30 days |
| Expedited plan appeal decision | 72 hours |
| Time to request State Fair Hearing | 120 days from plan's final appeal decision |
| Continue-benefits request window | 10 days from notice of action |
Plans this applies to
- Medicaid managed care organisations (MCOs)
- Prepaid Inpatient Health Plans (PIHPs)
- Prepaid Ambulatory Health Plans (PAHPs)
- PCCM entities
Frequently asked questions
What does 42 CFR 438 Subpart F require?
42 CFR Part 438 Subpart F requires every Medicaid managed care plan (MCO, PIHP, PAHP) to maintain a grievance and appeal system that gives enrollees (1) a right to file a grievance about any complaint not related to a coverage decision, (2) an internal plan appeal of any adverse benefit determination, and (3) the right to a State Fair Hearing AFTER exhausting internal appeal. States may add to the federal floor but cannot subtract. Expedited timelines: 72 hours when standard timeframes would seriously jeopardise the enrollee's life or health.
When do I cite 42 CFR 438 Subpart F in an appeal?
Cite 42 CFR 438 Subpart F on every Medicaid managed care denial. Note that Medicaid enrollees often have RIGHT TO CONTINUE BENEFITS during appeal (§438.420) — services that were previously authorised must continue at the previous level until the appeal is resolved, if the enrollee requests it within 10 days of notice. This is unique to Medicaid and very powerful when prior auth is being pulled mid-treatment.
What are the key deadlines under 42 CFR 438 Subpart F?
Time to file internal appeal: 60 days from notice of action. Standard plan appeal decision: 30 days. Expedited plan appeal decision: 72 hours. Time to request State Fair Hearing: 120 days from plan's final appeal decision. Continue-benefits request window: 10 days from notice of action
Which plans does 42 CFR 438 Subpart F apply to?
Medicaid managed care organisations (MCOs); Prepaid Inpatient Health Plans (PIHPs); Prepaid Ambulatory Health Plans (PAHPs); PCCM entities.
Related
- CARC 50Common denial code where 42 CFR 438 Subpart F applies.
- CARC 55Common denial code where 42 CFR 438 Subpart F applies.
- CARC 96Common denial code where 42 CFR 438 Subpart F applies.
- CARC 197Common denial code where 42 CFR 438 Subpart F applies.
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Sources
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