Medicaid1 SANDHILLS CENTER PARTICIPATING PROVIDER VIOLATIONS AND DISPUTE RESOLUTIONS (Medicaid &...

Medicaid Medicaid 11

SANDHILLS CENTERSANDHILLS CENTERPARTICIPATING PROVIDER PARTICIPATING PROVIDER VIOLATIONS AND DISPUTE VIOLATIONS AND DISPUTE

RESOLUTIONS RESOLUTIONS (Medicaid & State Funded)(Medicaid & State Funded)


SCOPE OF DISPUTE SCOPE OF DISPUTE RESOLUTION PROCEDURERESOLUTION PROCEDURE

The dispute resolution process is for The dispute resolution process is for Sandhills Center network providers Sandhills Center network providers

that wish to dispute a Sandhills that wish to dispute a Sandhills Center decision/action related to Center decision/action related to

Administrative Matters and/or those Administrative Matters and/or those related to Professional Competence related to Professional Competence

or Conduct.or Conduct.


PROCEDURE FOR PANEL DISPUTES PROCEDURE FOR PANEL DISPUTES CONCERNING PROFESSIONAL COMPETENCE CONCERNING PROFESSIONAL COMPETENCE

OR CONDUCTOR CONDUCT SHC is made aware of a providers desire to dispute a SHC is made aware of a providers desire to dispute a

decision/course of action by SHC through the decision/course of action by SHC through the submission of a completed “Provider Request for submission of a completed “Provider Request for Dispute Resolution of an Action form”.Dispute Resolution of an Action form”.

The form and supporting documentation must be submitted in The form and supporting documentation must be submitted in writing to the Network Management Manager within 7 calendar days writing to the Network Management Manager within 7 calendar days (Medicaid) or 30 calendar days (State Funded) of notification of the (Medicaid) or 30 calendar days (State Funded) of notification of the decision/action by SHC. decision/action by SHC.

Return receipt should be requested whether delivered by mail or in Return receipt should be requested whether delivered by mail or in person.person.


PROCEDURE FOR PANEL DISPUTES CONCERNING PROCEDURE FOR PANEL DISPUTES CONCERNING PROFESSIONAL COMPETENCE OR CONDUCTPROFESSIONAL COMPETENCE OR CONDUCT

Providers are notified in writing by registered mail verifying receipt of Providers are notified in writing by registered mail verifying receipt of the Dispute Resolution of an Action Form.the Dispute Resolution of an Action Form.

Reimbursement will continue during the reconsideration process Reimbursement will continue during the reconsideration process unless the provider is cited for gross negligence or suspected of unless the provider is cited for gross negligence or suspected of committing fraud or abuse. Note: continued reimbursement is likely committing fraud or abuse. Note: continued reimbursement is likely to increase any payback amount due if the action is upheld.to increase any payback amount due if the action is upheld.

The provider may be required to submit documentation for services The provider may be required to submit documentation for services delivered in order to continue to receive reimbursement during the delivered in order to continue to receive reimbursement during the reconsideration process.reconsideration process.



The Network Operations Director or designee convenes The Network Operations Director or designee convenes the First Level Dispute Panel. Panel Membership the First Level Dispute Panel. Panel Membership consists of:consists of:

Network Operations Director, or their designeeNetwork Operations Director, or their designee Customer Services Director, or their designeeCustomer Services Director, or their designee Quality Management Director, or their designeeQuality Management Director, or their designee Two (2) Providers who are members of the SHC provider network.Two (2) Providers who are members of the SHC provider network. At least one (1) of the providers reviewing the dispute will be a At least one (1) of the providers reviewing the dispute will be a

clinical peer of the provider who filed the dispute.clinical peer of the provider who filed the dispute. If necessary the First Level Panel will make an ad hoc appointment If necessary the First Level Panel will make an ad hoc appointment

for a clinical peer if one is not available within the Network. for a clinical peer if one is not available within the Network.



Any identifying information will be Any identifying information will be “blinded” prior to review by providers “blinded” prior to review by providers participating on the Panel:participating on the Panel:

The Panel reviews the information submitted by the The Panel reviews the information submitted by the provider and a decision is rendered based on majority provider and a decision is rendered based on majority vote within 14 calendar days of the receipt of the vote within 14 calendar days of the receipt of the request.request.

The Panel responds by registered mail return receipt The Panel responds by registered mail return receipt requested within 7 calendar days (Medicaid) 30 days requested within 7 calendar days (Medicaid) 30 days (State Funded), outlining the decision and further steps (State Funded), outlining the decision and further steps in the dispute process.in the dispute process.



SHC’s Chief Executive Officer, Finance Department, SHC’s Chief Executive Officer, Finance Department, Network Department, Quality Management, and the SHC Network Department, Quality Management, and the SHC Attorney all will be advised of the final decision from the Attorney all will be advised of the final decision from the First Level Panel.First Level Panel.

All paybacks are due and payable by the provider upon completion All paybacks are due and payable by the provider upon completion of the reconsideration. All payment to the provider shall cease of the reconsideration. All payment to the provider shall cease unless and until the required payback is paid in full.unless and until the required payback is paid in full.

Paybacks shall be paid by withholding reimbursement payments Paybacks shall be paid by withholding reimbursement payments due to the provider or by direct repayment to SHC, as specified in due to the provider or by direct repayment to SHC, as specified in an approved payment plan.an approved payment plan.

Approval of a payback payment plan shall be made by the Finance Approval of a payback payment plan shall be made by the Finance Officer in writing.Officer in writing.

All payments due to the provider shall continue to be withheld until All payments due to the provider shall continue to be withheld until either the payback is paid in full or a payback payment plan is either the payback is paid in full or a payback payment plan is approved in writing.approved in writing.



If the provider presents information to challenge If the provider presents information to challenge the findings of the First Level Dispute Panel, a the findings of the First Level Dispute Panel, a Second Level Dispute Panel will be convened. Second Level Dispute Panel will be convened.

The provider has 7 calendar days (Medicaid), 30 The provider has 7 calendar days (Medicaid), 30 calendar days (State Funded) from receipt of the calendar days (State Funded) from receipt of the First Level Panel response to submit the request First Level Panel response to submit the request to the Network Management Manager with any to the Network Management Manager with any

new supporting documentation for new supporting documentation for reconsideration by the Second Level Panel. reconsideration by the Second Level Panel.



The same review process will be followed as in the The same review process will be followed as in the first panel review. However, clinical peers served first panel review. However, clinical peers served

in the first review will not serve on the Second in the first review will not serve on the Second Level Panel for the same dispute. New clinical Level Panel for the same dispute. New clinical

peers will be appointedpeers will be appointed



If the provider is not satisfied with the final SHC If the provider is not satisfied with the final SHC decision involving Medicaid funded services, the decision involving Medicaid funded services, the provider may file a Petition for Reconsideration provider may file a Petition for Reconsideration Review with the Division of Medical Assistance:Review with the Division of Medical Assistance:

Appeals UnitAppeals UnitClinical Policy and ProgramsClinical Policy and Programs

NC Division of Medical AssistanceNC Division of Medical Assistance2501 Mail Service Center2501 Mail Service CenterRaleigh, NC 27699-2501Raleigh, NC 27699-2501



Medicaid Appeals are governed by 10A NCAC Medicaid Appeals are governed by 10A NCAC 22J.0101 et seq. which gives the provider the 22J.0101 et seq. which gives the provider the

right to file an appeal with the DMA within thirty right to file an appeal with the DMA within thirty (30) calendar days of the receipt of the final (30) calendar days of the receipt of the final notification from SHC. If the request is not notification from SHC. If the request is not

received within the 30 days, SHC’s decision is received within the 30 days, SHC’s decision is considered final. The request for consideration considered final. The request for consideration

review must be in writing, signed by the provider, review must be in writing, signed by the provider, contain provider’s name, address, and telephone contain provider’s name, address, and telephone number. It must state the specific reason for the number. It must state the specific reason for the

request and mailed to the address above.request and mailed to the address above.



If the provider disagrees with the decision by DMA, If the provider disagrees with the decision by DMA, the provider may request a contested case the provider may request a contested case

hearing with the Office of Administrative hearing with the Office of Administrative Hearings pursuant to Chapter 150B of the Hearings pursuant to Chapter 150B of the

General Statutes.General Statutes.



If the provider is not satisfied with the decision If the provider is not satisfied with the decision involving State funded services, an appeal may involving State funded services, an appeal may

be made to the State Mental Health, be made to the State Mental Health, Developmental Disabilities, and Substance Developmental Disabilities, and Substance

Abuse Appeals Panel under G.S. 122-151.4 Abuse Appeals Panel under G.S. 122-151.4 Providers not satisfied with the decision must file Providers not satisfied with the decision must file an appeal using the procedure in Session Law an appeal using the procedure in Session Law 2009-526, Section 10.15 (A). (e2) for appeals 2009-526, Section 10.15 (A). (e2) for appeals filed on or after July 1, 2008 and not GS 122-filed on or after July 1, 2008 and not GS 122-

151.4.151.4.


PROCEDURE FOR DISPUTES INVOLVING PROCEDURE FOR DISPUTES INVOLVING ADMINISTRATIVE MATTERSADMINISTRATIVE MATTERS

This process will follow a similar procedure as Disputes concerning This process will follow a similar procedure as Disputes concerning Professional Competence or Conduct.Professional Competence or Conduct.

The Network Operations Director, Chief Operating Officer, and Quality The Network Operations Director, Chief Operating Officer, and Quality Management Director or their designees will review the information Management Director or their designees will review the information submitted by the provider within 14 calendar days of receipt of the submitted by the provider within 14 calendar days of receipt of the request. A response will be sent by registered mail, return receipt request. A response will be sent by registered mail, return receipt requested, within 7 calendar days if involving Medicaid services, requested, within 7 calendar days if involving Medicaid services, outlining the decision and further steps in the dispute process. outlining the decision and further steps in the dispute process.

If State Funded services are involved the information submitted by the If State Funded services are involved the information submitted by the provider will be reviewed and responded to in writing within 30 days provider will be reviewed and responded to in writing within 30 days of receipt of the request, outlining the decision and further steps in of receipt of the request, outlining the decision and further steps in

the dispute process.the dispute process.


Sandhills Center for MH, IDD & SASSandhills Center for MH, IDD & SAS

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