CMS Pub. 100-11, ch. 11, § 20.3

In addition to the standard appeals process, the PACE organization must have an

expedited appeals process in place for situations in which the participant believes that if

the service is not furnished, his or her life, health, or ability to regain or maintain

maximum function would be seriously jeopardized.

The PACE organization must respond to the appeal as expeditiously as the participant’s

health condition requires, but no later than 72 hours after it receives the appeal. The 72-hour timeframe may be extended by up to 14 calendar days if the participant requests the

extension or the PACE organization justifies to the State Administering Agency the need

for additional information and how the delay is in the interest of the participant.

The PACE organization must take appropriate action to furnish the disputed service as

expeditiously as the health condition of the participant requires if, on appeal, a

determination is made in favor of the participant.

The PACE organization is required to notify CMS, the State Administering Agency, and

the participant of its determination that is wholly or partially adverse to a participant at

the time the decision is made. CMS notification may be accomplished through the HPMS

Data Element for monitoring reporting.

[42 CFR § 460.122(f), (h), and (g)]