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Medicaid Non-Emergency Transportation Complaints, Grievances, Appeals and Medicaid Fair Hearings July 13, 2010 18 th Annual Transportation Disadvantaged.

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Presentation on theme: "Medicaid Non-Emergency Transportation Complaints, Grievances, Appeals and Medicaid Fair Hearings July 13, 2010 18 th Annual Transportation Disadvantaged."— Presentation transcript:

1 Medicaid Non-Emergency Transportation Complaints, Grievances, Appeals and Medicaid Fair Hearings July 13, th Annual Transportation Disadvantaged Training & Technology Conference G. Douglas Harper Medical/Health Care Program Analyst

2 Discussion Items Overview: – Complaints – Grievances – Appeals – Medicaid Fair Hearing General Requirements Description and Resolution Procedures: – Complaint – Grievances – Appeals – Medicaid Fair Hearing Suggestions for Record Keeping 2

3 Overview The Contract uses the Centers for Medicare and Medicaid Services (CMS) requirements used as the basis for: (1)Complaints; (2)Grievances; (3)Appeals; and (4)Medicaid Fair Hearings. 3

4 Complaints Rider’s concerns about a provider’s quality of service Who can file? – A Rider – A Rider’s representative Rider or Rider’s representative files by calling the Grievance/Appeal Coordinator Are resolved either at the time the Rider contacts the provider or within 1 Business Day of the Rider’s complaint. Examples: – Rudeness or timeliness of service 4

5 Examples of a Complaint Rider calls saying that his bus is late: – Customer service representative checks location of vehicle and tells the Rider it is 5 minutes away; or – Customer service representative checks scheduled pick up time and sees that the doctor’s appointment is on Wednesday and it is Tuesday and notifies the Rider of the correct pickup date and time. The Rider realizes the mistake and hangs up. In both instances, the customer service representative is able to assist the Rider immediately without further investigation. 5

6 Grievances A Rider’s concern about a provider’s quality of service. The provider cannot resolve the issue within 1 Business Day. Who can file: – Rider; or – Rider’s representative. Rider or Rider’s representative files by calling the Grievance/Appeal Coordinator. Must be resolved within 90 days of receiving the Grievance. 6

7 Example of a Grievance Rider contacts provider and states that a driver was rude to the Rider during pick up, while in transit and/or at drop-off. – The provider has to take longer than one Business Day in order to complete an adequate investigation and take any disciplinary action (if necessary). 7

8 Appeals Results from a denial or limitation of services. Either the Rider or the Rider’s representative can file an Appeal. Examples of actions that can result in an Appeal: – Denial of transportation due to lack of eligibility; – Request that rider change of medical appointment to meet regular transportation schedule (out of county, etc.); or – Limitation of transportation services due to Rider’s conduct (unless approved by a previous Appeal and/or Medicaid Fair Hearing). 8

9 Medicaid Fair Hearings An administrative law process that allows a Rider to request the State to reconsider a provider’s decision that is adverse to the Rider. – A Medicaid Fair Hearing is an Administrative Hearing presented before an Administrative Hearing Officer who makes a ruling based on all the evidence presented by both sides. Appeals and Medicaid Fair Hearings are virtually identical. – The Appeal process is run by the provider. – The Medicaid Fair Hearing is run by a State hearing officer. 9

10 Medicaid Fair Hearings (con’t.) A Rider can request a Medicaid Fair Hearing either following, or at the same time as, the Rider pursues a Grievance or Appeal. A Rider, the Rider’s representative or the Rider’s health care provider can request a Medicaid Fair Hearing. Parties include the Rider (and his representative or the representative of the Rider’s estate) and the STP/CTC. 10

11 General Requirements First place to look for guidance is the STP Agreement, which offers some direction and lists the federal requirements that all providers must follow (See Section VII of the TP Agreement). All providers must have a Grievance System in place that includes policies and procedures for a: – Complaint process; – Grievance process; – Appeal process; and – Medicaid Fair Hearing process. Acknowledge Grievances and Appeals in writing. 11

12 General Requirements (con’t.) The provider must ensure that no decision makers on a Grievance or Appeal were involved in the decision making process in the original: – Appeal of a denial of services based on lack of Medical Necessity; or – Grievance regarding the denial of an expedited resolution of an Appeal. The provider must allow the Rider and the Rider’s representative to have access to the Rider’s case file before and during the Grievance or Appeal process, including all documents and records. Providers must maintain, monitor and review a complete record or log of all Complaints, Grievances and Appeals. 12

13 General Requirements Notice Send written notice to Beneficiaries if: – Denial of transportation services; or – Limitation of access to transportation services. Written notice in addition to the oral notification. – If the CTC/STP provides any oral notification to the Rider, the CTD/STP must send written notice on the same day as the denial or limitation of transportation services. Notice must be as close as possible to the 4 th grade reading level and obtain approval from the Agency before use. – The CTD has Agency approved templates. – Drop down menu for various options. Reason Codes “Other” 13

14 General Requirements Notice (con’t) The notice must include: – Type of action (limitation or denial of services); – Reason; – Regulation or change in law that allows provider to limit or deny services; 42 Code of Federal Regulations 431 Subpart E and Florida Administrative Code Chapter through – Explanation of Rider’s rights; – Rider’s right to provide evidence; – Expedited resolutions; and – Continuation of transportation services. 14

15 Complaints The provider must: – Resolve each Complaint in 1 day, but can take up to 15 Business Days if necessary; 10 Business Day extension – Written notification within 5 Business Days of the resolution; Includes results and date of resolution; and Notice of right to Grievance or Appeal; – Report all Complaints to the CTD; and – Take no punitive action towards the Rider. 15

16 Grievances The provider must: – Resolve each Grievance within 90 Calendar Days of receipt; – Provide written notification to the Rider within 30 Calendar Days of resolution; – Provide copy of written notice of disposition; Includes notice of right to Medicaid Fair Hearing, if applicable – Take no punitive action; and – Report all Grievances to the CTD. 16

17 Grievances (con’t.) The provider can extend Grievance time frame by 14 Calendar Days: – Rider can request an extension; – Provider can request an extension if there is a need for additional information and that delay is in the Rider’s best interest; and – Written notice of extension to the Rider and reason for the delay. Filing requirements: – 1 year to file a Grievance. – Rider may file orally or in writing, but 90 Calendar Day resolution time period begins upon receipt of the first notification. 17

18 Appeals The provider must: – Confirm all oral inquiries in writing, unless it is an expedited resolution; – Provide Rider with opportunity to present evidence and allegations of fact or law; – Provide Rider with written notice of the resolution of the Appeal within 2 Business Days of the resolution; – If the resolution is not wholly in the Rider’s favor of the notice of resolution must include: Notice of right to request a Medicaid Fair Hearing; How to request a Medicaid Fair Hearing; Right to continue to receive transportation services pending the outcome of the Medicaid Fair Hearing; How to continue transportation services pending the Medicaid Fair Hearing; and That the Rider may be liable for costs if Medicaid Fair Hearing favors the provider. 18

19 Appeals (con’t) – Continue Rider’s transportation services if: The Rider files the Appeal within 10 Business Days (15 if sent by US postal service) of the intended effective date of the provider’s proposed date of limitation, suspension or denial of transportation services Appeal involves termination, suspension or reduction of previously authorized transportation services; Transportation services were for a Medicaid compensable service; The medical services authorization period has not expired; and Rider requests extension of transportation services 19

20 Appeals (con’t) – If resolution is in favor of Rider, provide medically appropriate transportation as quickly as necessary; – Ensure that neither you nor your employees/subcontractors take any punitive action; and – Provide the CTD with a report of total number of Appeals and status as set forth in the Reporting Requirements section of the provider contract. 20

21 Appeals (con’t) If Rider receives transportation services while Appeal is pending, the provider must continue transportation services until: – The Rider withdraws the Appeal; – 10 Business Days after the provider notifies the Rider of an adverse Appeal resolution and the Rider has not requested a Medicaid Fair Hearing with continuation of transportation services; – The Medicaid Fair Hearing decision is adverse to the Rider; or – The Rider’s authorization to receive services expires or the Rider meets authorized service limits. 21

22 Appeals (con’t) Provider can recover costs of transportation services provided during an Appeal if the Appeal is adverse to the Rider and if the services were furnished solely because of the requirements of the Appeal process. – Example – Rider denied transportation services for a medical checkup unrelated to transportation services received for dialysis. The provider can recover the costs of the transportation for the medical checkup, but not for the transportation services to and from the dialysis center. 22

23 Appeals (con’t) If the provider does not furnish transportation services while the Appeal is pending, and the Appeal overturns the denial or limitation, the provider must authorize transportation services for the Rider as quickly as the Rider’s health requires. The provider must pay for disputed services if the Appeal panel reverses the provider’s decision to deny, limit or delay transportation services to a Rider. If CTC/STP denied services and Rider had to pay out of pocket for transportation, the CTC/STP must reimburse the Ricer for the cost of the transportation. If the provider did not furnish services while the Appeal was pending and the Appeal panel reverses the provider’s decision, the provider must pay for the disputed transportation services. 23

24 Appeals Filing Requirements 30 Calendar Days from receipt of notice to file an Appeal. Rider can file orally or in writing. Rider must file a written Appeal within 30 Calendar Days of the oral filing. The provider must notify the Rider within 10 Business Days of receipt of an oral Appeal of the requirement for a written Appeal. The time frames for resolution of the Appeal begin on the date the provider received the oral filing. 45 Calendar Days to resolve an Appeal. Rider or provider can request a 14 Calendar Day extension. Provider must notify the Rider of the reasons for the extension within 5 Business Days of determining the need for an extension. 24

25 Appeals Expedited Process Providers must have a process for reviewing expedited Appeals where the standard resolution time could seriously jeopardize a Rider’s life, health or ability to attain, maintain or regain maximum function. Rider can file orally or in writing. No written follow up necessary for oral requests. 25

26 Appeals Expedited Process (cont’d) The provider must: – Notify Rider of limited time to present allegations of fact or law; – Resolve the Appeal within 72 hours (3 calendar days) of receipt, oral or written; – Provide written notice to the Rider of the resolution of the Appeal; – Attempt to contact the Rider orally immediately after the provider renders a decision; and – Ensure that no party takes punitive action against the Rider. 26

27 Appeals Expedited Process (con’t) If the provider denies a request for an expedited resolution of an Appeal, the provider must: – Transfer the Appeal to the standard time frame (45 Calendar Days); – Provide the Rider with immediate oral notification; – Provide written notice to the Rider within 2 Calendar Days; – Fulfill all standard Appeal processes. 27

28 Medicaid Fair Hearings A Rider has the right to pursue a Medicaid Fair Hearing at the same time as he pursues resolution through the Grievance and Appeal process. Request the Medicaid Fair Hearing within 90 Calendar Days of notice of resolution of a Grievance or Appeal. Provider must give notice of right to a Medicaid Fair Hearing. 28

29 Medicaid Fair Hearings Provider Duties The provider must: – Continue transportation services if the Rider filed for a Medicaid Fair Hearing in a timely manner, meaning either: – Within 10 Business Days (add 5 Business Days if mailed by US postal service) of the notice of action; or – On or before the intended effective date of the termination, limitation, reduction or denial of transportation services; The Medicaid Fair Hearing involves the termination, limitation, reduction or denial of transportation services; The authorization period has not expired; and/or The Rider requests an extension of transportation services. – Ensure that no punitive action is taken against a Rider who files for a Medicaid Fair Hearing. 29

30 Medicaid Fair Hearing Provider Duties (con’t) If the Rider requests to continue transportation services pending the Medicaid Fair Hearing, the provider must continue transportation services until one of the following occurs: – The Rider withdraws the transportation request; – 10 Business Days pass (add 5 Business Days if the provider uses US postal service) between the provider sending notice that outcome of Grievance/Appeal was adverse to the Rider and the Rider does not request a Medicaid Fair Hearing with a continuation of transportation services; – Medicaid Fair Hearing decision is adverse to the Rider; and/or – The Rider’s authorization for medical treatment expires or the Rider reaches the authorized medical treatment limit. 30

31 Medicaid Fair Hearing Provider Duties (con’t) If final resolution to Medicaid Fair Hearing is adverse to the Rider, the provider may recover the costs for providing transportation services pending the outcome of the Medicaid Fair Hearing. If the provider did not provide transportation services while the Medicaid Fair Hearing was pending and the Medicaid Fair Hearing officer reverses the provider’s decision, the provider must provide the transportation services as quickly as the Rider’s health condition requires. If the provider did not furnish services while the Medicaid Fair Hearing was pending and the Medicaid Fair Hearing officer reverses the provider’s decision, the provider must pay for the disputed transportation services. 31

32 Summary of Time Frames Type Time Frame to File Provide Transportatio n Services During Review Time Frame to Resolve Extension Time Frame Time Frame to Send Notification of Resolution Next Step (if any) Complaint Ninety (90) Calendar Days from the date of the incident that precipitated the Complaint Yes Fifteen (15) Business Days Ten (10) Business Days Five (5) Business Days from the date of the Complaint Grievance Ninety (90) Calendar Days from the date of the incident that precipitated the Grievance Yes Ninety (90) Calendar Days Fourteen (14) Calendar Days Thirty (30) Calendar Days from the date of the Resolution Medicaid Fair Hearing Appeal Thirty (30) Calendar Days of the Rider receiving notice of the denial, limitation or delay of transportation services Yes Forty-five (45) Calendar Days Fourteen (14) Calendar Days Thirty (30) Calendar Days from the date of resolution of the Appeal Medicaid Fair Hearing Upon the Rider filing a Grievance or Appeal Yes Resolution by Administrative Hearing None Notification sent by the Administrative Hearing Office Legal Recourse 32

33 Suggestions for Recording Keeping Keep a written log or record of all Complaints, Grievances and Appeals in the event that they go to a Medicaid Fair Hearing. Call 911 and the law enforcement immediately for any altercation (assault, threats, etc.). File a police report. Additionally, for Medicaid Fair Hearings, it is helpful to: – Driver available; – Police officer available; and – Consult with a lawyer. 33

34 Questions? 34


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