Okaloosa County BOCC — 2013 meeting #1139 (date undetermined) — MEDICAID ORIGINAL 2009 — reading text

broken down by county. Starts upon Commencement of The number of Encounter Data Found by Counting Each Submission of Encounter Data Medicaid Beneficiary "No Show" in the "Trip No Shows, broken Indicator" Field down by county. 01/01/2010 The average waiting Encounter Data Found by Subtracting time for a scheduled "Trip Actual Pickup pickup, broken down Time" by "Reservation by county. Pick Up Time" 01/01/2010 The average travel Encounter Data Found by Subtracting time that a Medicaid "Trip Actual Pickup Beneficiary must lime" by "Trip remain in a vehicle Destination Drop Off from the point of pick Time" up to the destination, broken down by transportation mode and county. 2. For the Performance Measures that must begin reporting via Encounter Data on January 1, 2010, the Commission shall collect a sample of the data manually, as described below, from those STPs that are not able to submit the information electronically upon the date of commencement of Encounter Data submission. - --- -- a. Upon the start date of this Contract, the STP shall require all drivers to record Performance Measure information on all driver manifests. b. Upon the start date of this Contract, STPs shall monitor the driver manifests on a monthly basis by examining .a statistically Significant sample of driver manifests to determine the timeliness of reporting. The STPs shall submit their on-time pickup and delivery report either directly to the Commission using the Medicaid Encounter Data System (MEDS System).The STP shall submit the on time pickup and delivery reports using the MEDS System by January 1, 2010. c. Until the STP begins submitting Performance Measure information via the MEDS System, STPs shall submit all Performance Measure information to the Commission for review to be submitted to the AHCA. (1) If it is determined that a STP is excessively late in picking up and/or delivering Medicaid Beneficiaries to their destinations, the Commission or the AHCA shall require the STP to initiate a 2008/2009 Medicaid Non~Emergency Transportation Subcontracted Transportation Provider Contract Page 50 of 117  Corrective Action Plan (CAP) to explain how the STP will pick up and/or deliver Medicaid Beneficiaries in a timely manner. (2) If the STP is unable to meet the requirements set forth in the CAP to pick up or deliver Medicaid Beneficiaries on time, the Commission shall require the STP to begin electronic submission of Performance Measure information using the Encounter Data System, within sixty (60) calendar Days of the determination or by January 1, 2010, whichever comes first. (3) Those STPs that are able to submit the Performance Measure information electronically upon the start date of this contract shall not be required to submit sampling reports as described above. VII. GRIEVANCE SYSTEM A. Overview 1. Description a. Complaint process - The Complaint process is the Commission's and the STP's procedure for addressing Medicaid Beneficiary Complaints, which are expressions of dissatisfaction about any matter other than an Action that are resolved at the Point of Contact rather than through filing a formal Grievance. b. Grievance process - The Grievance process is the Commission's and the STP's procedure for addressing Medicaid Beneficiary Grievances, which are expressions of dissatisfaction about any matter other than an Action. c. Appeal process - The Appeal process is the Commission's and the STP's procedure" for addressing Medicaid Beneficiary Appeals,""which are requests for review of an Action. d. Medicaid Fair Hearing process - The Medicaid Fair Hearing process is the administrative process which allows a Medicaid Beneficiary to request the State to reconsider an adverse decision made by the Commission or the STP. 2. General Requirements a. ' The Commission and the STP shall have a Grievance System in place that includes a Complaint process, a Grievance process, an Appeal process, and access to the Medicaid Fair Hearing system. The Grievance System shall comply with the requirements set forth in Section 641.511, F.S., if applicable and with all applicable federal and State laws and regulations, including 42 CFR 431.200 and 42 CFR 438, Subpart F, "Grievance System." 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 51 of 117  b. The STP must develop and maintain written policies and procedures relating to the Grievance System. Before implementation, the Commission must give the STP written approval of the STP's Grievance System policies and procedures. c. The STP shall refer all Medicaid Beneficiaries who are dissatisfied with the STP or its Actions to the STP's Grievance/Appeal Coordinator for processing and documentation in accordance with this Contract and established policies and procedures. d. The STP shall provide reasonable assistance to Medicaid Beneficiaries in completing forms and other procedural steps, including, but not limited to, providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability. e. The STP shall acknowledge, in writing, the receipt of a Grievance or a request for an Appeal, unless the Medicaid Beneficiary requests an expedited resolution. f. The STP shall not allow any of the decision makers on a Grievance or Appeal were involved in any of the previous levels of review or decision- making when deciding any of the following: (1) An Appeal of a denial that is based on lack of Medical Necessity; and, (2) A Grievance regarding the denial of an expedited resolution of an Appeal. g. The Medicaid Beneficiary, and/or the Medicaid Beneficiary's representative, shall be allowed an opportunity to examine the Medicaid Beneficiary's case file before and during the Grievance or Appeal process, including all Medical Records and any other documents and records. h. The Medicaid Beneficiary and/or the Medicaid Beneficiary's representative or the representative of a deceased Medicaid Beneficiary's estate shall be conSidered as parties to the Grievance!Appeal. i. The STP shall maintain, monitor, and review a record/log of all Complaints, Grievances, and Appeals in accordance with the terms of this Contract and to fulfill the reporting requirements as set forth in this Contract. . j. The STP shall work with the Commission's Grievance/Appeals Coordiator to resolve all grievance related issues. k. Notice of Action . 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 52 of 117 .  (1) The STP shall notify the Medicaid Beneficiary, in writing, using language at, or below the fourth (4th) grade reading level, of any Action taken by the STP to deny a Transportation Service request, or limit Transportation Services in an amount, duration, or scope that is less than requested. (2) The STP shall provide notice to the Medicaid Beneficiary as set forth below (see 42 CFR 438.404(a) and (c) and 42 CFR 438.210(b) and (c»: (a) The Action the Recipient has taken or intends to take; (b) The reasons for the Action, customized for the circumstances of the Medicaid Beneficiary; (c) The Medicaid Beneficiary's or the Health Care Professional's (with written permission of the Medicaid Beneficiary) right to file an Appeal; (d) The procedures for filing an Appeal; (e) The Circumstances under which expedited resolution is available and. how to request it; and, (f) The Medicaid Beneficiary's rights to request that