Exhibit 14. Grievance and Appeal System

Transcription

1 Exhibit 14 Grievance and Appeal System General Requirements The ICS will develop, implement and maintain written internal grievance and appeal policies and procedures that comply with all Title XXI requirements and timeframes included in the (CMSN) Complaints, Appeal and Grievances policy. Exhibit 14 Grievance & Appeal System

2 CMS NETWORK COMPLAINT, APPEAL AND GRIEVANCE LOG (see for full policy & procedures) Date: CMS LOG NUMBER: CMS Staff Name: Enrollment Type: Title XXI CMS CMS Safety Net Title XIX/Medicaid (refer to Medicaid processes) Child s Name: Last: First: MI: Date of Birth: Child s SSN: Title XXI Individual ID CMS MMI or Family Account Number Write number here: Complainant or Grievant s Name Last: First: MI: Appendix A Translator/language: Relationship to child: If complainant is a representative, required Parent Legal Guardian Representative Appointment of Representation completed and Child Provider returned to CMS: Yes No Address City State Zip Code Home Phone (with area code) Work Phone (with area code) Cell Phone (with area code) Fax number (with area code) COMPLAINT Received on (date): Briefly describe complaint and resolution: APPEAL requested: Orally (written request required within 10 calendar days of oral request, except for expedited review) In writing Appeal not requested Expedited review requested? Yes No (enrollee s physician or CMSN determination required) Date of appeal request: Continuation of health services requested? Yes No (health service terminations, reductions or suspensions only) Action being Appealed: Health service delayed Health service reduction Health service termination Health service suspension Health service denial Other (briefly describe): Date of Notice of Action to be appealed: Resolved to complainant s satisfaction? Yes No If no, date Request for Appeal and form mailed to complainant: Is date of appeal request within 90 calendar days of notice of action? Yes No If continuation of health services requested, was request the later of within 10 business days of notice of action or 10 business days of intended effective date of action? Yes No Date of ICS or Regional CMS Appeal Committee meeting, if requested in writing: Did complainant participate in the appeal meeting? Yes, in person Yes, by conference call No GRIEVANCE requested in writing on (date): Date of CMSN Statewide Grievance Panel Meeting: Date of ICS or Regional CMS Appeal Committee decision: Expedited review requested? Yes No (enrollee s physician or CMSN determination required) Did grievant participate in the panel meeting? Yes No Briefly describe appeal decision: Continuation of health services requested? Yes No (health service terminations, reductions or suspensions only) Date of Panel Recommendation: If continuation of health services requested, was request within 10 business days of notice of appeal decision? Yes No Date of Deputy State Health Officer s final decision: Briefly describe final grievance resolution: July 2012

3 Page 1 of 11 SECTION TABLE OF CONTENTS PAGE I. Policy 2 II. Authority 2 III. Supportive Data 2 IV. Signature Block with Effective Date 2 V. Definitions 2 VI. Protocols: 4 A. Outcomes 4 B. Personnel 4 C. Competencies 4 D. Areas of Responsibility 4 VII. Procedures 4 A. (CMS) Complaint, Appeal and Grievance Procedure Exceptions 4 B. Continuation of Health Services 5 C. Complaint Resolution 6 D. Appeal/Internal Review Procedures 6 E. Grievance/External Review Procedures 9 F. Expedited Review Procedures 10 VIII. Distribution List 10 IX. History Notes 10 X. Appendices 11 Appendix A: CMS Complaint, Appeal and Grievance Log Appendix B: CMS Appeal Request Appendix C: CMS Grievance Request Appendix D: CMS Appointment of Representation

4 Page 2 of 11 I. Policy A. Upon enrollment in the CMS, families and providers must be advised of the process for filing complaints and grievances, which are written procedures detailing an organized process by which enrollees and providers may seek resolution. B. Services to enrollees will not be adversely affected by any complaint or grievance action initiated on their behalf. II. Authority Section , F.S.; Section (2), F.S.; 59G-14, Florida KidCare Grievance Process; Federal Child Health Insurance Program Reauthorization Act; 42 CFR Part , State of Florida Title XXI State Plan Amendment III. Supportive Data None. IV. Signature Block with Effective Date: Signature on file CMSN Florida KidCare Director Date Mary Beth Vickers, R.N., M.S.N. Acting Division Director Date V. Definitions The following definitions are applicable to the Title XXI-funded Children s Medical Services and Safety Net. A. Action: The delay, denial, reduction, suspension, or termination of health services to a enrollee, including a determination about the type or level of services; or failure to approve, furnish, or provide payment for health services in a timely manner.

5 Page 3 of 11 B. Appeal or internal review: A formal request from a complainant to seek a review of an action. An appeal may be filed orally or in writing within ninety (90) calendar days of the date of the notice of action and, except when expedited review is required, must be followed with a written notice within ten (10) calendar days of the oral filing. The date of oral notice or written notice, whichever is earlier, shall constitute the date of receipt. C. Complaint: A verbal or written expression of dissatisfaction. D. Complainant: A parent, a legal guardian, an authorized representative of the parent or legal guardian, an enrollee whose disability of nonage has been removed, or a provider submitting a complaint. If a parent, legal guardian or an enrollee whose disability of nonage has been removed appoints a representative to discuss a complaint on their behalf, they must complete and sign an Appointment of Representation (Appendix D) that names the representative and gives the representative access to medical records in compliance with the Health Insurance Portability and Accountability Act (HIPAA). E. Complaint resolution: The initial process used to address a complaint. F. Enrollee: A child who has been determined eligible for and is receiving health services from the through Title XXI-funded Florida KidCare or CMS Safety Net. G. Emergency medical condition: This term has the same meaning as defined in s (9), F.S. H. Grievance or external review: A formal written request initiated to challenge an action after the appeal process has been exhausted. I. Grievant: A parent, a legal guardian, an authorized representative of the parent or legal guardian, an enrollee whose disability of nonage has been removed, or a provider submitting a grievance. If a parent, legal guardian or an enrollee whose disability of nonage has been removed appoints a representative to discuss a grievance on their behalf, they must complete and sign an Appointment of Representation (Appendix D) that names the representative and gives the representative access to medical records in compliance with the Health Insurance Portability and Accountability Act (HIPAA). J. Health services: Medical and dental benefits provided to an enrollee in the. K. Integrated Care System: A comprehensive contracted program of health services for children with special health care needs. This is the core service delivery structure of the.

6 Page 4 of 11 L. Third Party Administrator: An entity contracted by the Florida Healthy Kids Corporation that is responsible for administrative services, including eligibility determination, for the Title XXI-funded Florida KidCare Program, as authorized in s , F.S. M. Title XIX: Title XIX of the Social Security Act, the Medicaid Program. Medicaid is an entitlement program and eligibility is determined by the Department of Children and Families. N. Title XXI: Title XXI of the Social Security Act, the federal Children s Health Insurance Program. This is a non-entitlement program referred to as the Florida KidCare Program. VI. Protocols Not applicable. A. Outcomes All complaints, appeals and grievances for enrolled clients in the CMS will be processed according to established policy. B. Personnel CMS Area Office Staff C. Competencies Knowledge of the CMS Complaint, Appeals policy D. Areas of Responsibility CMSN Florida KidCare Director VII. Procedures A. (CMS) Complaint, Appeal and Grievance Procedure Exceptions 1. For Medicaid beneficiary issues involving eligibility, enrollment or renewal, or termination, suspension, reduction or denial of Medicaid covered services; families request a Medicaid Fair Hearing by contacting the Department of Children and Families (DCF) as referenced in Rule et seq., F.A.C. 2. For Medicaid provider issues involving eligibility or reimbursement, the provider accesses the Florida Division of Administrative Hearings or the court system. 3. For Florida KidCare issues involving Florida KidCare third party administrator determinations of eligibility, enrollment, disenrollment or renewal, a complainant accesses the Florida KidCare grievance process.

7 Page 5 of For CMS issues that are unrelated to the CMS, a complainant accesses the respective CMS program s grievance procedures. 5. A complaint about a employee that is not resolved through the complaint resolution process will be addressed in accordance with state personnel rules and regulations. B. Continuation of Health Services 1. A Title XXI-funded CMS enrollee s health services may be reinstated or continued at the prior level if: a. A request for continuation of health services is received within 10 business days of the date of the notice of action or within 10 business days of the intended effective date of the action, whichever is later; b. The disputed action involves the termination, reduction or suspension of a previously authorized course of treatment; c. The health services were ordered by an authorized provider; and d. The original period covered by the original authorization has not expired. 2. If disputed health services are continued while the appeal is pending, the health services will continue until one of the following occurs: a. The request for the appeal is withdrawn; b. Ten (10) business days pass after the date of notice of resolution of the appeal, unless the complainant within those ten (10) business days has requested a grievance review by the CMS Statewide Grievance Panel; c. If the enrollee is Title XXI-funded, cancellation of coverage. Health services that are unrelated to an emergency medical condition will not be continued during the Title XXI cancellation period; d. The time period or service limits of a previously authorized disputed health service have been met; or e. The final grievance resolution decision is not in favor of the enrollee.

8 Page 6 of If the disputed health services are continued or reinstated pending the final resolution, the complainant or grievant must be informed of their legal responsibility for paying back the costs of disputed health services rendered during the continuation period if the final resolution is not in the enrollee s favor. C. Complaint Resolution 1. The complaint resolution process begins when a complainant notifies a CMS Area Office Medical Director, Nursing Director, Program Administrator, Care Coordinator or Member Services representative verbally or in writing of a complaint. 2. CMS area office staff will document receipt of the verbal or written complaint and a brief description of its final resolution in the CMS Complaint, Appeal and Grievance Log (Appendix A) maintained in a secure location. 3. The CMS area office staff will attempt to resolve the complaint through prompt communication with the complainant. If the complaint is resolved to the satisfaction of the complainant, no further action will be taken. 4. If the complaint is not resolved to the satisfaction of the complainant within 2 business days following the receipt of the complaint, the complainant may choose to pursue the appeal/internal review process. D. Appeal/Internal Review Procedures 1. An appeal may be requested orally or in writing. The date of oral notice or written notice, whichever is earlier, shall constitute the date of receipt. An oral request must be followed with a written notice within ten (10) calendar days of the oral filing. A written appeal must be signed and dated by the complainant, and must be date stamped when received. The CMS Area Office will provide assistance in preparing the written appeal upon request. A CMS Appeal Request (Appendix B) will be provided to the complainant. If a complainant chooses not to use a CMS Appeal Request, the following information will be included in the written request for an appeal: a. Enrollee s full name and date of birth b. Enrollee s Florida KidCare individual identification number, if applicable c. Complainant s name, if not the enrollee d. Name of provider who ordered the health service e. Name of provider requesting the appeal, if applicable f. Type of action in dispute (e.g., delay, denial, reduction, suspension or termination)

9 Page 7 of 11 g. Duration and frequency of the disputed health service, if applicable h. Medical necessity of the health service to include additional documentation as needed to support the request i. If the provider is out of network, documentation to substantiate that the health service cannot be performed by a CMS provider j. A copy of the original notice of action in dispute k. If a continuation of disputed health services is being requested 2. The CMS Area Office shall make an entry in the CMS Complaint, Appeal and Grievance Log (Appendix A) for each appeal and grievance including a brief description of its final resolution. 3. The CMS Area Office will maintain a secure Complaint, Appeal and Grievance file which includes: a. A record of each formal appeal filed, recorded on the CMS Appeal Request or in a document containing the elements of the Appeal Request; b. A complete description of the factual findings and the final resolution of the appeal and grievance, if applicable; c. A copy of all decision letters; and d. All supporting documentation related to the appeal and grievance, if applicable. 4. The complainant shall have the opportunity before appeal proceedings to examine the case file, including medical records, and any other material to be considered during the proceedings. 5. If an enrollee receives health services from an Integrated Care System, the Integrated Care System s appeal committee must be accessed. The committee will not include individuals who rendered the original decision in the notice of action. a. The Integrated Care System will notify the complainant of its decision within 45 calendar days of receipt of the complainant s request for a review of an action. The time frame may be extended up to 14 calendar days, if the complainant requests an extension. b. If the complainant is dissatisfied with the Integrated Care System s decision, the complainant may request a grievance review by notifying the CMS Area Office or the CMS Central Office

10 Page 8 of 11 grievance coordinator in writing. CMS Area Office assistance to prepare the grievance request will be provided upon request. c. The CMS Area Office is responsible for collecting and logging the appeal and accompanying documentation identified in Section D.3 from the Integrated Care System, and transmitting the information to the CMS Central Office grievance coordinator to initiate grievance proceedings. Secure, encrypted may be used to transmit documentation. If hard copy transmission is required, overnight delivery, return receipt requested, will be used. The CMS Area Office will notify the CMS Central Office grievance coordinator when grievance materials are being transmitted. 6. If an enrollee does not receive health services from an Integrated Care System, the appeal will be reviewed by the regional CMS Appeal Committee. The committee will include the CMS Regional Medical Director or Assistant Medical Director, the regional Nursing Director or designee, regional Program Administrator or designee, and at least two other CMS Area Office staff members with the expertise needed to resolve the disputed action, as identified by the CMS Nursing Director or Program Administrator. The committee will not include individuals who rendered the original decision in the notice of action. a. Within five (5) business days after receipt of the written notification from the complainant, the CMS Area Office will contact the complainant in writing with the scheduled date and time of the regional CMS Appeal Committee meeting and that the complainant may provide additional written materials if received by a date-certain. The complainant may elect to attend the scheduled meeting in person or by conference call. If the complainant is unable to attend the scheduled meeting, the regional CMS Appeal Committee will meet in the complainant s absence. b. If the appeal involves the collection of information from outside the service area, the CMS Area Office is responsible for requesting and creating a file of the relevant information. c. The regional CMS Appeal Committee shall review the appeal and supporting documentation and make a decision regarding the disputed action. d. The Committee s decision will be communicated in writing to the complainant under the signature of the CMS Area Office Medical Director or Assistant Medical Director within 45 calendar days of receipt of the complainant s written request for an appeal. The

11 Page 9 of 11 time frame may be extended up to 14 calendar days, if the complainant requests an extension. 7. If the complainant is dissatisfied with the regional CMS Appeal Committee s decision, the complainant may request a CMS Statewide Grievance Panel review of the decision by notifying the CMS Area Office in writing. A request for a grievance review must be date stamped when received. A CMS Grievance Request (Appendix C) will be provided to the grievant. If a grievant chooses not to use a CMS Grievance Request, their letter also must indicate if a continuation of health services is being requested. CMS Area Office assistance to prepare the grievance request will be provided upon request. 8. If the grievant requests a review by the CMS Statewide Grievance Panel: a. Within three (3) business days of receipt of the written request the CMS Area Office will transmit the written request and all supporting documentation related to the grievance to the CMS Central Office grievance coordinator. b. Secure, encrypted may be used to transmit documentation. If hard copy transmission is required, overnight delivery, return receipt requested, will be used. The CMS Area Office will notify the CMS Central Office grievance coordinator when grievance materials are being transmitted. E. Grievance/External Review Procedures 1. A grievance review is available only after the appeal process has been exhausted. 2. The CMS Statewide Grievance Panel, located at CMS Central Office, is responsible for reviewing the appropriateness of the appeal decision and making a recommendation to the Deputy State Health Officer for. 3. The CMS Statewide Grievance Panel includes the Division Director or designee, one physician and three other CMS Central Office staff members who have the expertise needed to resolve the issue. If the enrollee receives health services from an Integrated Care System, a CMS Area Office representative will be a panel member in lieu of one CMS Central Office staff member. 4. All records reviewed by the CMS Statewide Grievance Panel will be maintained in the CMS Central Office in a secure location.

12 Page 10 of Within seven (7) calendar days after receipt of the grievance request, the CMS Central Office will notify the grievant in writing of the scheduled meeting date and time of the CMS Statewide Grievance Panel meeting, that the grievant may provide additional written materials if received by a date-certain, and that the grievant may elect to attend the meeting by conference call. If the grievant is unable to participate in the scheduled meeting, the Panel will meet in the grievant s absence. 6. The grievant shall have the opportunity before grievance panel proceedings to examine the case file, including medical records, and any other material to be considered during the proceedings. 7. The panel will review the grievance documents, including additional written materials timely submitted by the grievant, and make a written recommendation to the Deputy State Health Officer for Children s Medical Services to accept or modify the appeal decision. 8. The final decision on the grievance will be communicated in writing to the grievant under the signature of the Deputy State Health Officer for or designee within 45 calendar days of receipt of the grievant s written request for a grievance review by the CMS Statewide Grievance Panel. 9. The decision of the Deputy State Health Officer for Children s Medical Services is final for all health service issues. F. Expedited Review Procedures An expedited review must be completed within 72 hours of the time a complainant or grievant requests the review if the enrollee s physician or the determines that operating under the standard time frame could seriously jeopardize the enrollee s life or health or ability to attain, maintain or regain maximum function. The Children's Medical Services may extend the 72-hour time frame by up to 14 calendar days, if the complainant or grievant requests an extension. VIII. IX. Distribution List Area Offices History Notes None

13 Page 11 of 11 X. Appendices Appendix A: CMS Complaint, Appeal and Grievance Log R:\KidCare\CMS T21 policy handbook Secti Appendix B: CMS Appeal Request R:\KidCare\CMS T21 policy handbook Secti Appendix C: CMS Grievance Request R:\KidCare\CMS T21 policy handbook Secti Appendix D: CMS Appointment of Representation R:\KidCare\CMS T21 policy handbook Secti