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

2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 56 of 117 .  (2) The Medicaid Beneficiary or provider may file a Grievance either orally or in writing. The Medicaid Beneficiary may follow up an oral request with a written request, however the timeframe for resolution begins the date the STP receives the oral request. D. The Appeal Process 1. A Medicaid Beneficiary may file an Appeal, or a representative of the Medicaid Beneficiary, acting on behalf of the Medicaid Beneficiary and with the Medicaid Beneficiary's written consent, may file an Appeal. 2. General Duties a. The STP shall: (1) Confirm in writing all oral inquiries seeking an Appeal, unless the Medicaid Beneficiary or provider requests an expedited resolution; (2) If the resolution is in favor of the' Medicaid Beneficiary, provide the services as quickly as the Medicaid Beneficiary's health condition requires; (3) Provide the Medicaid Beneficiary or provider with a reasonable opportunity to present evidence and allegations of fact or law, in person and/or in writing; (4) Allow the Medicaid Beneficiary, and/or the Medicaid Beneficiary's representative, an opportunity, before and during the Appeal process, to examine the Medicaid Beneficiary's case file,. including . all documents and records; (5) Consider the Medicaid Beneficiary, the Medicaid Beneficiary's representative or the representative of a' deceased Medicaid Beneficiary's estate as parties to the Appeal; (6) Continue the Medicaid Beneficiary's Transportation Services if: (a) The Medicaid Beneficiary files the Appeal in a timely manner, meaning on or before the later of the following: (i) Within ten (10) Business Days of the date on the notice of Action (add five [5] Business Days if the notice is sent via Surface Mail); or, (iJ) The intended effective date of the STP's proposed Action. 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 57 of 117  (b) The Appeal involves the termination, suspension, or reduction of· a previously authorized Transportation service; (c) The Transportation was for a Medicaid compensable service ordered; (d) The authorization period has not expired; and/or, (e) The Medicaid Beneficiary requests extension of Transportation Services. (7) Provide written notice of the resolution of the Appeal, including the results and date of the resolution within two (2) Business Days after the resolution. For decisions not wholly in the Medicaid Beneficiary's favor, the notice of resolution shall include: (a) Notice of the right to request a Medicaid Fair Hearing; (b) Information about how to request a Medicaid Fair Hearing, including the DCF address necessary for pursuing a Medicaid Fair Hearing, as set forth in Medicaid Fair Hearing System Section, below; (c) Notice of the right to continue to receive Transportation Services pending a Medicaid Fair Hearing; (d) Information about how to request the continuation of Transportation Services; and (e) a Nbticethafifthe STP's Actioriis upheicJ iri Medicaid Fair Hearing, the Medicaid Beneficiary may be liable for the cost of any continued Transportation Services. (8) Provide the Commission with a copy of the written notice of disposition upon request; (9) The STP nor any Transportation Providers shall take any punitive action against a physician or other health care provider who files an Appeal on behalf of a Medicaid Beneficiary or supports a Medicaid Beneficiary's Appeal; and, (10) Provide the Commission with a report detailing the total number of Appeals received, pursuant to Reporting Requirements of this Contract. b. If the STP 'continues or reinstates the Medicaid Beneficiary's Transportation Services while the Appeal is pending, the STP must 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 58 of 117  continue providing the Transportation Services until one (1) of the following occurs: (1) The Medicaid Beneficiary withdraws the Appeal; (2) Ten (10) Business Days pass from the date of the STP's notice of resolution of the Appeal if the resolution is adverse to the Medicaid Beneficiary and if the Medicaid Beneficiary has not requested a Medicaid Fair Hearing with continuation of Transportation Services until a Medicaid Fair Hearing decision is reached; (3) The Medicaid Fair Hearing panel's decision is adverse to the Medicaid Beneficiary; or, (4) The authorization to provide services expires, or the Medicaid Beneficiary meets the authorized service limits. c. If the final resolution of the Appeal is adverse to the Medicaid Beneficiary, the STP may recover the costs of the services furnished from the Medicaid Beneficiary while the Appeal was pending, to the extent that the STP furnished the services solely because of the requirements of this Section. d. If the STP did not furnish services while the Appeal was pending and the Appeal panel reverses the STP's decision to deny, limit or delay services, the STP must authorize or provide the disputed services promptly and as quickly as the Medicaid Beneficiary's health condition requires. e. If the. STP furnished. services. while the Appeal. was ,pending and the . . Appeal-panel reverses the STP'sdeCisionlP -deny; limit ordeiaYservices, the STP must pay for disputed services in accordance with State policy and regulations. . 3. Filing Requirements a. The Medicaid Beneficiary or his/her representative must file an Appeal within thirty (30) Calendar Days of receipt of the notice of the STP's Action. b. The Medicaid Beneficiary may file an Appeal either orally or in writing. If the filing is oral, the Medicaid Beneficiary must also file a written, signed Appeal within thirty (30) Calendar Days of the oral filing. The STP shall notify the requesting party that it must file the written request within ten (10) Business Days after receipt of the oral request. For oral filings, time frames for resolution of the Appeal begin on the date the STP receives the oral filing. 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page S9 of 117  c. The STP shall resolve each Appeal within State-established time frames not to exceed forty-five (45) Calendar Days from the day the STP received the initial Appeal request, whether oral or in writing. d. If the resolution is in favor of the Medicaid Beneficiary, the STP shall provide the services as quickly as the Medicaid Beneficiary's health condition requires. e. The STP may extend the resolution time frames 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 STP requests the extension, the STP must give the Medicaid Beneficiary written notice of the reason for the delay. (2) The STP must provide written notice of the extension to the Medicaid Beneficiary within five (5) Business Days of determining the need for an extension. 4. Expedited Process a. The STP shall establish and maintain an expedited review process for Appeals when the STP determines, the Medicaid Beneficiary requests or the provider indicates (in making the request on the Medicaid Beneficiary's behalf or supporting the Medicaid Beneficiary's request) that taking the time for a standard resolution could seriously