Prisoner Health Care Standards
IV. APPEALS/DENIALS PROCESS
Nothing in the USMS Prisoner Health Care
Appeals Procedure is intended to create or does create an enforceable
legal right or private right of action.
A. APPEALS
The USMS reviews requests for health care
services and supplies to ensure that prisoners in the custody of the
USMS are provided basic minimum health care. The USMS Prisoner
Healthcare Standards are used as the guideline for making health care
recommendations to the districts. When a requested medical service is
not in accordance with the standards, it will be referred to OIMS for
review and determination.
Appeals for denial of a requested
prisoner health care service that are based on OIMS interpretation of
USMS medical policy may be initiated by:
- the prisoner;
- a medical provider, or a legally
appointed advocate (defense attorney, legal guardian) in writing to
the USMS
The appeal should state why there should
be an exception to USMS medical policy (e.g. not in agreement with the
policy or extenuating circumstances exist to form an exception). The
USMS will review and recommend a resolution.
The USMS shall forward the recommendation
and supporting medical records for review by the USMS Medical Appeals
Board. After reviewing the request and records, the USMS Medical Appeals
Board will either:
- uphold the decision of denial;
overturn and approve the request; or
- seek further information or a second
opinion from a consultant.
B. DENIALS
All denials of payment for prisoner
health care services will be reviewed by the OIMS physician consultant.
The following denials of payment may be recommended by the medical case
coordinators without review by the OIMS physician consultant:
- The prisoner is not in the custody
of the USMS;
- The requested services are not a
covered benefit.
All other denials of payment will be
reviewed for concurrence by the physician consultant.
Upon final review of all provided
documentation, a written recommendation will be forwarded to the USMS.
All communication will include an explanation for the recommendation.
C. USMS APPEALS BOARD
The USMS Medical Appeals Board shall meet
to review appeals submitted to OIMS. The Board will consist of:
- one representative from the USMS
Office of General Counsel (OGC);
- one health care professional
representative from OIMS;
- one health care specialist in the
relevant field;
- one representative from the
Investigations and Detentions Branch.
The health care representative will not
be the physician consultant nor the individual who initially reviewed
the case.
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