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

jeopardize the Medicaid Beneficiary's life, health or ability to attain, maintain or regain maximum function. b. The Medicaid Beriefidary may an ftle expedited Appeal either orally ~r· in writing. No additional written follow-up on the part of the Medicaid Beneficiary is required for an oral request for an expedited Appeal. c. The STP must: (1) Inform the Medicaid Beneficiary of the limited time available for the Medicaid Beneficiary to present evidence and allegations of fact or law, in person and in writingi (2) Resolve each expedited Appeal and provide notice to the Medicaid Beneficiary, as quickly as the Medicaid Beneficiary's health condition requires, within State established time frames not to exceed seventy-two (72) hours after the Recipient/Subcontractor receives the Appeal request, whether the Appeal was made orally or in writing; 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 60 of 117  (3) Provide written notice of the resolution in accordance with the Appeal Process Section, of the expedited Appeal to the Medicaid Beneficiary; (4) Make reasonable efforts to provide oral notice of disposition to the Medicaid Beneficiary immediately after the Appeal panel renders a decision; and, (5) The STP nor any Transportation Provider shall take any punitive action against a physician or other health care provider who requests an expedited resolution on the Medicaid Beneficiary's behalf or supports a Medicaid Beneficiary's request for expedited resolution of an Appeal. a. If the STP denies a request for an expedited resolution of an Appeal, the STP must: (1) Transfer the Appeal to the standard time frame of no longer than forty-five (45) Calendar Days from the day the Recipient/Subcontractor received the request for Appeal (with a possible fourteen [14] day extension); (2) Make all reasonable efforts to provide immediate oral notification of the Recipient's/Subcontractor's denial for expedited resolution of the Appeal; (3) Provide written notice of the denial of the expedited Appeal within two (2) Calendar Days; and, (4) Fulfill all requirements set forth in the Appeal Process Section above. E. Medicaid Fair Hearing System 1. As set forth in Rule 65-2.042, FAC, the Recipient's/Subcontractor's Grievance Procedure and Appeal and Grievance processes shall state that the Medicaid Beneficiary has the right to request a Medicaid Fair Hearing, in addition to, and at the same time as, pursuing resolution through the Recipient's/Subcontractor's Grievance and Appeal processes. a. A physician or other health care provider must have a Medicaid Beneficiary's written consent before requesting a Medicaid Fair Hearing on behalf of a Medicaid Beneficiary. 2008/2009 Medicaid Non-Emergenc.y Transportation Subcontracted Transportation Provider Contract Page 61 of 117  b. The parties to a Medicaid Fair Hearing include the STP, as well as the Medicaid Beneficiary, his/her representative or the representative of a deceased Medicaid Beneficiary's estate. 2. Filing Requirements a. The Medicaid Beneficiary may request a Medicaid Fair Hearing within ninety (90) days of the date of the notice of the STP's resolution of the Medicaid Beneficiary's Grievance/Appeal by contacting DCF at: The Office of Appeal Hearings 1317 Winewood Boulevard, Building 5, Room 203 Tallahassee, Florida 32399-0700 3. General Duties a. The STP must: (1) Continue the Medicaid Beneficiary's Transportation Services while the Medicaid Fair Hearing is pending if: (a) The Medicaid Beneficiary filed for the Medicaid Fair Hearing 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); (Ii) The inteiidedeffective date of the STP's proposed Action. (b) The Medicaid Fair Hearing involves the termination, suspension, or reduction of a previously authorized course of treatment; (c) The authorization period has not expired; and/or, (d) The Medicaid Beneficiary· requests extension of Transportation Services. (2) The STP nor any Transportation Provider shall take any punitive action against a physician, Transportation Provider, or other health care provider who requests a Medicaid Fair Hearing on a Medicaid Beneficiary's behalf or supports a Medicaid Beneficiary's request for a Medicaid Fair Hearing. 2008{2009 Medicaid Non·Emergency Transportation Subcontracted Transportation Provider Contract Page 62 of 117  b. If the STP continues or reinstates Medicaid Beneficiary Transportation Services while the Medicaid Fair Hearing is pending, the STP must continue said Transportation Services until one (1) of the following occurs: (1) The Medicaid Beneficiary withdraws the request for a Medicaid Fair Hearing; (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 the Medicaid Beneficiary has not requested a Medicaid Fair Hearing with continuation of Transportation Services until a Medicaid Fair Hearing decision is reached (add five [5] Business Days if the Recipient/Subcontractor sends the notice of Action by Surface Mail); (3) The Medicaid Fair Hearing officer renders a decision that Is adverse to the Medicaid Beneficiary; and/or, (4) The Medicaid Beneficiary's authorization expires or the Medicaid BenefiCiary reaches his/her authorized service limits. 4. If the final resolution of the Medicaid Fair Hearing is adverse to the Medicaid BenefiCiary, the STP may recover the costs of the services fumished while the. Medicaid Fair Hearing was pending, to the extent that the STP furnished said services solely because of the reqUirements of this Section. 5. If the STP did not furnish services while the Medicaid Fair Hearing was pending, and the Medicaid Fair Hearing resolution reverses the STP's deciSion to deny, limit or delay services, the STP must authorize or provide the disputed services as quickly as the Medicaid Beneficiary's health condition requires. 6. If the STP did furnish services while the Medicaid Fair Hearing was pending, and the Medicaid Fair Hearing resolution reverses the STP's decision to deny, limit or delay services, the STP must pay for the disputed services in accordance with State policy and regulations. Type Time Frame to File Provide Time Frame Extension Time Frame to Next Step Transportation to Resolve Time Frame Send (ifany) Services During Notification of Review Resolution Complaint Ninety (90) Calendar Yes Fifteen (lS) Ten (10) Five (5) File a Days From the Date of Business Days BUSiness Days Business Days Grievance the Incident That From the Date Precipitated the of the Complaint Complaint 2008/2009 Medicaid Non-Emergency Transportation