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

Transportation Services continue pending the resolution of the Appeal, how to request the continuation of Transportation Services, and the circumstances under which the Medicaid BenefiCiary may be reqUired to pay the costs of these services. (3) The STP must provide the notice of Action within the following time frames: (a) At least ten (10) Calendar Days before the date of the Action or fifteen (15) Calendar Days if the notice is sent by Surface Mail (five [5] Calendar Days if the Recipient suspects Fraud on the part of the Medicaid Beneficiary). See 42 CFR 431.211, 42 CFR 431.213 and 42 CFR 431.214. (b) For denial of the Trip request, at the time of any Action affecting the Trip request. (c) For standard Service Authorization decisions that deny or limit Transportation Services, as quickly as the Medicaid Beneficiary's health condition requires, but no later than 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 53 of 117  fourteen (14) Calendar Days following receipt of the request for service (see 42 CFR 438.210(d)(1)). (d) If the STP extends the time frame for notification, it must: (i) Give the Medicaid Beneficiary written notice of the reason for the extension and inform the Medicaid Beneficiary of the right to file a Grievance if the Medicaid Beneficiary disagrees with the Recipient's decision to extend the time frame; and, (ii) Carry out its determi,nation as quickly as the Medicaid Beneficiary's health condition requires, but in no case later than the date upon which the fourteen (14) Calendar Day extension period expires (see 42 CFR 438.210(d)(1)). (e) If the STP fails to reach a decision within the time frames described above, the Medicaid BenefiCiary can conSider such failure on the part of the STP a denial and, therefore, an Action adverse to the Medicaid Beneficiary (See 42 CFR 438.210(d)). (f) For expedited Service Authorization deciSions, within three (3) Business Days (with the possibility of a fourteen (14) Calendar Day extension). See 42 CFR 438.21O(d)(2). B. The Complaint Process 1. A Medicaid BenefiCiary may file a Complaint, or a representative of the Medicaid BenefiCiary, acting on behalf of the Medicaid BenefiCiary and with the Medicaid Beneficiary's written consent, may file a Complaint. 2. General Duties a. The STP must: (1) Resolve each Complaint within fifteen (15) Business Days from the day the STP received the initial Complaint, be it oral or in writing; (a) The STP may extend the Complaint resolution time frame by up to ten (10) Business Days if the Medicaid Beneficiary requests an extension, or the Recipient/Subcontractor documents that there is a need for additional information and that the delay is in the Medicaid Beneficiary's best interest. 2008/2009 Medicaid Non·Emergency Transportation Subcontracted Transportation Provider Contract Page 54 of 117  (b) If the STP requests the extension, the Recipient/Subcontractor must give the Medicaid Beneficiary written notice of the reason for the delay. (2) Notify the.Medicaid Beneficiary, in writing, within five (5) Business Days of the resolution of the Complaint if the Medicaid Beneficiary is not satisfied with the STP's resolution. The notice of disposition shall include the results and date of the resolution of the Complaint, and shall include: (a) A notice of the right to request a Grievance or Appeal, whichever is the most appropriate to the nature of the objection; and, (b) Information necessary to qllow the Medicaid Beneficiary to request a Medicaid Fair Hearing, if appropriate, including the contact information necessary to pursue a Medicaid Fair Hearing (see Medicaid Fair Hearing System Section). (3) Provide the Commission with a report detailing the total number of Complaints received, pursuant to Reporting Requirements of this contract; and, (4) The STP nor any Transportation Providers shall take any punitive action against a physician or other Health Care Provider who files a Complaint on behalf of a Medicaid Beneficiary, or supports a Medicaid Beneficiary's Complaint. b. Filing Requirements (1) .. The Medicaid Beneficiary or a representative-C;ffheMedicaid Beneficiary, acting on behalf of the Medicaid Beneficiary and with the Medicaid Beneficiary's written consent must file a Complaint within fifteen (15) Calendar Days after the date of occurrence that initiated the Complaint. (2) The Medicaid Beneficiary or his/her representative may file a Complaint either orally or in writing. The Medicaid Beneficiary or his/her representative may follow up an oral request with a written request, however the timeframe for resolution begins the date the STP receives the oral request. C. The Grievance Process 1. A Medicaid Beneficiary may file a Grievance, or a representative of the Medicaid Beneficiary, acting on behalf of the Medicaid Beneficiary and with the Medicaid Beneficiary's written consent, may file a Grievance. 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 55 of 117  2. General Duties a. The STP must: (1) Resolve each Grievance within ninety (90) Calendar Days from the day the STP received the initial Grievance request, be it oral or in writing; (2) Notify the Medicaid Beneficiary, in writing, within thirty (30) Calendar Days of the resolution of the Grievance. The notice of disposition shall include the results and date of the resolution of the Grievance, and for decisions not wholly in the Medicaid Beneficiary's favor, the notice of disposition shall include: (a) Notice of the right to request a Medicaid Fair Hearing, if applicable; and, (b) Information necessary to allow the Medicaid Beneficiary to request a Medicaid Fair Hearing, including the contact information necessary to pursue a Medicaid Fair Hearing (see Medicaid Fair Hearing System Section, below); (3) Provide the Commission with a copy of the written notice of disposition upon request; (4) The STP nor any Transportation Provider shall take any punitive action against a physician or other health care provider who files a Grievance on behalf of a Medicaid Beneficiary, or supports a Medicaid Beneficiary's Grievance; and, (5) Provide the Commission with a reportdetililingthe totaillumber of Grievances received, pursuant to the Reporting Requirements Section of this Contract. b. The STP may extend the Grievance resolution time frame by up to fourteen (14) Calendar Days if the Medicaid Beneficiary requests an extension, or the STP documents that there is a need for additional information and that the delay is in the Medicaid Beneficiary's best interest. (1) If the STPrequests the extenSion, the STP must give the Medicaid Beneficia ry written notice of the reason for the delay. c. Filing Requirements (1) The Medicaid Beneficiary or provider must file a Grievance within one (1) year after the date of occurrence that initiated the Grievance.