Section 409.818(3)(e), F.S. directs the Agency for Health Care Administration (AHCA) to establish a mechanism for investigating and resolving complaints and grievances for the Florida KidCare Program. The purpose of the proposed rule is to establish ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO: RULE TITLE
59G-14.001: Definitions
59G-14.002: Confidentiality
59G-14.003: Federal Compliance
59G-14.004: Florida KidCare Dispute Review Process
59G-14.005: Florida KidCare Grievance Committee
59G-14.006: Florida KidCare Grievance Procedures
59G-14.007: Health Care Services Complaints and Disputes
PURPOSE AND EFFECT: Section 409.818(3)(e), F.S. directs the Agency for Health Care Administration (AHCA) to establish a mechanism for investigating and resolving complaints and grievances for the Florida KidCare Program. The purpose of the proposed rule is to establish the AHCA’s Florida KidCare grievance process in rule.
In the Notice of Rule Development, the title of the rule Chapter 59G-14, F.A.C., was Florida KidCare; and we published preliminary text for two rules: 59G-14.001, Definitions, and 59G-14.002, Florida KidCare Grievance Process. We renamed the rule chapter 59G-14, Florida KidCare Grievance Process, and divided the Florida KidCare Grievance Process into six separate rules: 59G-14.002 through 59G-14.007.
In the Notice of Rule Development, the title of the rule chapter 59G-14 was Florida KidCare; and we published preliminary text for two rules: 59G-14.001, Definitions, and 59G-14.002, Florida KidCare Grievance Process. We renamed the rule chapter 59G-14, Florida KidCare Grievance Process, and divided the Florida KidCare Grievance Process into six separate rules: 59G-14.002 through 59G-14.007.
SUMMARY: The purpose of the proposed rule is to establish the AHCA’s Florida KidCare grievance process in rule. The effect will be to incorporate AHCA’s Florida KidCare grievance process in rule.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 409.918 FS.
LAW IMPLEMENTED: 409.918 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: Monday, November 5, 2007, 2:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B, Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Angela Wiggins, Medicaid Services, 2727 Mahan Drive, Building 3, Mail Stop 20, Tallahassee, Florida 32308-5407, [phone], [e-mail] florida.com.

THE FULL TEXT OF THE PROPOSED RULE IS:

 

CHAPTER 59G-14 FLORIDA KIDCARE
GRIEVANCE PROCESS

59G-14.001 Definitions.

The following definitions are applicable to the Title XXI, Florida KidCare Programs (Children’s Medical Services Network, Florida Healthy Kids and MediKids) and to all sections of Florida KidCare Grievance Procedures, Chapter 59G-14, F.A.C. These definitions do not apply to any complaint or grievance issues relating to Medicaid for Children eligibility, enrollment or renewal activities. For Medicaid eligibility and enrollment complaint or grievance issues, families must request a Medicaid Fair Hearing by contacting the Department of Children and Family Services (DCF) as referenced in Rule 65-2.042, et. seq., F.A.C.

(1) “Applicant” refers to a parent or guardian of a child or a child whose disability of nonage has been removed under chapter 743, who applies for eligibility under subsections 409.810-409.820, F.S. (Florida KidCare Act).

(2) “Complaint” or “dispute” is a verbal or written expression of dissatisfaction, regarding an eligibility or enrollment decision.

(3) “Complainant” or “grievant” is a parent, legal guardian, or an authorized representative of the parent or legal guardian who submits a complaint or grievance on behalf of a child enrolled in Florida KidCare. If a parent or legal guardian appoints a representative to discuss the complaint or grievance on their behalf, they must complete and sign an Appointment of Representation Form, AHCA Med-Serv Form 017, August 2007, one page, and the Authorization for the Use and Disclosure of Protected Health Information Form, AHCA Med-Serv Form 018, August 2007, two pages, which are incorporated by reference. These forms name the representative and give the representative access to medical records in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

(4) “Dispute Resolution Hearing” is the complainant’s opportunity to be heard by the Florida KidCare Dispute Review Panel during the third level of the Florida KidCare Formal Dispute Review Process. If requested, a professionally transcribed hearing is scheduled between the complainant and the Florida KidCare Dispute Review Panel in the complainant’s county of residence.

(5) “Florida KidCare Partners” include the Agency for Health Care Administration (MediKids), the Department of Children and Family Services (Medicaid for Children), the Department of Health (Children’s Medical Services Network), and the Florida Healthy Kids Corporation (Healthy Kids). Families with children receiving coverage under the Medicaid for Children Program must request a Medicaid Fair Hearing by contacting the Department of Children and Family Services (DCF) as referenced in Rule 65-2.042 to 65-2.066, , F.A.C.

(6) “Florida KidCare Formal Dispute Review Process” is a comprehensive review of an eligibility or enrollment complaint. The formal dispute review process begins when a written request to resolve a dispute is received by the Florida Healthy Kids Corporation’s Resolution Coordinator. The entire dispute review process is conducted by the Florida Healthy Kids Corporation, the eligibility processor for the Florida KidCare, Title XXI Programs.

(7) “ Florida KidCare Informal Dispute Review Process” is the initial contact in writing or telephone to the Florida Healthy Kids Corporation, expressing dissatisfaction with a disputable application or enrollment action.

(8) “Florida KidCare Grievance Committee” or “committee” is the entity responsible for hearing and resolving grievances related to the Florida KidCare Program when all avenues of resolutions through the Florida KidCare Dispute Review Process have been exhausted. For Medicaid eligibility and enrollment grievance issues, families must request a Medicaid Fair Hearing by contacting the Department of Children and Family Services (DCF) as referenced in Rules 65-2.042 to 65-2.066, F.A.C.

(9) “Grievance” means a formal written complaint initiated to challenge an eligibility or enrollment decision only after all other forms of resolution have been exhausted through the Florida KidCare Formal Dispute Review Process.

(10) “Health Services” means the medical benefits provided by an individual’s health care coverage (e.g., hospital services, physician services, prescription drugs and laboratory services).

(11) “Resolution Coordinator” is the person responsible for supervising the dispute review process and preparing a written response to the complainant explaining the Florida Healthy Kids Corporation or Florida KidCare Dispute Review Process decision regarding eligibility or enrollment.

(12) “Third Party Administrator” is the entity contracted by Florida Healthy Kids Corporation that is responsible for administrative services for the Florida KidCare Program, Title XXI Programs. These administrative services include: eligibility determination, referrals, enrollment, denials, premium processing, customer service, ongoing account maintenance and income and insurance verification.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New________.

 

59G-14.002 Confidentiality.

The Florida Healthy Kids Corporation Dispute Review Process and the Florida KidCare Grievance Review Process shall conform to Section 409.821, F.S., Health Insurance Portability and Accountability Act of 1996, and Title 42, Part 431, Subpart F of the Code of Federal Regulations with respect to confidentiality of information.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New _______.

 

59G-14.003 Federal Compliance.

The Florida KidCare Program shall have a process for Program specific review that meets the requirements of 42 CFR ss. 457.1130-457.1180 with respect to Applicant and Enrollee Protections.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New________.

 

59G-14.004 Florida KidCare Dispute Review Process.

(1) The Florida KidCare Dispute Review Process is the means by which the Florida KidCare Program provides a comprehensive review of complaints relating to eligibility, enrollment and health services. The Florida KidCare Dispute Review Process includes an informal and formal dispute review process.

(2) Disputes involve at least one of two topics:

(a) Denial of eligibility; which includes failure to make a timely determination of eligibility and suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.

(b) Health service matters consisting of a delay, denial, reduction, suspension, or termination of health services and failure to approve, furnish, or provide payment for health services in a timely manner.

(3) The Third Party Administrator for the Florida Healthy Kids Corporation determines eligibility for the non-Medicaid components of the Florida KidCare Program. The Florida Healthy Kids Corporation is responsible for reviewing eligibility and enrollment disputes. The Florida Healthy Kids Corporation Resolution Staff is responsible for conducting the Florida KidCare Dispute Review Process.

(4) The Florida KidCare Dispute Review Process is comprised of four review levels addressing the denial of eligibility, failure to make a timely determination of eligibility and suspension or termination of enrollment, including disenrollment for failure to pay the family premium. The Florida Healthy Kids Corporation shall provide information regarding the dispute review process in correspondence to families, making them aware of the existence and availability of the Florida KidCare Dispute Review Process.

(a) “Level One” initiates the informal dispute review for the Florida KidCare Dispute Review Process. The informal dispute review begins when a complainant calls a Florida KidCare customer service representative to discuss his or her dissatisfaction about an eligibility or enrollment decision. The initial contact can also be communicated in writing. The Florida KidCare customer service representative will attempt to clarify or resolve the dispute through the telephone conversation. If the complaint is resolved to the satisfaction of the complainant, no further action will be taken.

(b) If the Florida KidCare customer service representative determines that a dispute cannot be resolved through a telephone conversation, the Florida KidCare customer service representative shall request the complainant forward documentation concerning the dispute to the Florida Healthy Kids Corporation office. All Florida Healthy Kids Corporation customer service representatives and the Florida Healthy Kids Corporation’s Third Party Administrator representatives shall offer the complainant a dispute review form to assist them in filing a request for a dispute review. A dispute review form is not mandatory. The complainant can request to dictate to a Florida Healthy Kids Corporation resolution representative any information that is necessary to begin or supplement a formal dispute. During the dictation process, the complainant shall provide the following information to the Florida Healthy Kids Corporation resolution representative: complainant’s name, address, family account number, home and work telephone numbers; names of the children involved in the dispute, an explanation of the dispute and the names of other agencies sent a formal dispute about this matter.

(c) A written or e-mail request to begin the formal dispute review process shall be sent by the complainant to the Resolution Coordinator. A request to begin the formal dispute process must be initiated by a parent, guardian, or another individual listed on the Florida KidCare account as the person authorized to discuss all details of the account.

(d) The Resolution Coordinator shall send written acknowledgement to the complainant within three (3) calendar days after the Florida Healthy Kids Corporation receives a written request to initiate the Florida KidCare Formal Dispute Review Process. The written notification will explain all remaining levels of the Florida KidCare Dispute Review process to the complainant.

(e) If the complainant requests continuation of enrollment pending the completion of the review, the Florida Healthy Kids Corporation Dispute Resolution staff shall take the following steps:

1. Determine whether the complainant requested the continuation of enrollment within ten (10) calendar days of the date of the letter indicating the suspension or termination of his or her child(ren)’s enrollment.

2. If the request was not made within ten (10) calendar days of the date of the letter the complainant received informing him or her of suspension or termination of his or her children’s enrollment, the Florida Healthy Kids Corporation Dispute Resolution staff shall inform the complainant in writing of the denial of continuation of enrollment.

3. If the request was made within ten (10) calendar days of the date of the letter the complainant received informing him or her of suspension or termination of his or her child(ren)’s enrollment, the Florida Healthy Kids Corporation Dispute Resolution staff shall take the following action to ensure continuation of enrollment, if the child(ren) meets all other Florida KidCare Program qualifications:

a. Instruct the Third Party Administrator to stop the cancellation of the account or, if the account has already been cancelled, re-open the account back to the first day of the month in which the request for continuation was received.

b. If the dispute concerns an increase in the premium rate, the Third Party Administrator staff shall maintain the premium rate in effect prior to the notification of an increase.

(f) If the complainant’s children receive continuation of enrollment pending the completion of the dispute review process, the complainant must be aware of the following conditions:

1. All premium payments must be paid in a timely manner in order to maintain the coverage during the continuation period.

2. If the formal dispute review is resolved in favor of Florida KidCare and not the complainant, the complainant will be legally responsible for paying back all premiums and the costs of services rendered during the continuation period.

(g) Disputes which involve more than one Florida KidCare Program entity shall be immediately referred to the Florida KidCare Grievance Committee. The Resolution Coordinator shall send written notification to the complainant within three (3) calendar days and copy the relevant Florida KidCare Programs regarding a referral to the Florida KidCare Grievance Committee.

(h) The Resolution Coordinator shall review the complaint and make a determination regarding the complaint. The Resolution Coordinator shall send written notification to the complainant regarding the Level One Dispute Review decision.

(i) Level Two – Formal Dispute Review Process – The complainant can initiate the Level Two Formal Dispute Review Process verbally or in writing. The Resolution Coordinator shall send written notification to the complainant that the complaint has been forwarded to the Florida Healthy Kids Executive Director or a designee for review. The Resolution Coordinator shall also forward all pertinent review documents to the Florida Healthy Kids Executive Director or the designee, who shall render a decision regarding the request. The Florida Healthy Kids Executive Director or designee shall notify the complainant of the decision in writing within twenty (20) calendar days of the referral to the Level Two Formal Dispute Process.

(j) Level Three – Florida Healthy Kids Review Panel – If the complainant is dissatisfied with the decision determined at Level Two of the Florida KidCare Formal Dispute Review Process, the complainant can send a written request to the Florida KidCare Dispute Review Panel to further review the dispute.

(k) The Florida KidCare Dispute Review Panel shall schedule a dispute resolution hearing between the dispute review committee members and the complainant within thirty (30) calendar days from the date of the request. Florida Healthy Kids Corporation shall schedule a hearing in the complainant’s county of residence. The hearing shall be professionally transcribed. The Florida Healthy Kids Corporation shall be responsible for providing the transcriber. The complainant can waive the right to appear at the hearing. If the complainant waives the right to appear in-person at the hearing, the hearing shall be conducted at the Florida Healthy Kids Corporation Offices in Tallahassee, Florida. Members of the Dispute Review Panel may participate in either hearing via a telephone conference call.

(l) The Florida Healthy Kids Corporation Executive Director or designee shall consider all complainant requests for assistance and respond to each on a case-by-case basis (e.g., reimbursement for parking, requests for a translator, etc.).

(m) The Florida Healthy Kids Corporation Dispute Review Panel shall consist of three (3) voting members appointed by the Florida Healthy Kids Corporation’s Executive Director. The voting members shall consist of two (2) Florida Healthy Kids Corporation Board members chosen based on accessibility or availability for the dispute resolution hearing and one of these members shall serve as the Chair. A Consumer Representative shall be appointed from an entity that assists families with health care or eligibility issues. The Florida Healthy Kids Corporation Corporate Counsel or, if the Corporate Counsel is not available, the Florida Healthy Kids Corporation General Counsel shall serve as an advisor to the Dispute Review Panel.

(n) The following applies to the Dispute Resolution hearing:

1. The complainant shall be given an adequate opportunity to examine the contents of the Dispute Review file and all other relevant documents and records prior to the hearing. The complainant can request and receive a complete copy of the materials provided to the Dispute Review Panel members prior to the hearing at no charge.

2. The complainant can represent themselves at the hearing or be assisted by a representative.

3. Complainants shall provide the names of any additional attendees (and their affiliations) they would like to have present at the hearing to the Resolution Coordinator in advance to be added to the hearing agenda.

(o) The Dispute Review Panel shall make a decision to approve or deny the complainant’s dispute. The Resolution Coordinator shall notify the complainant of the Dispute Review Panel’s decision in writing within ten (10) calendar days of the hearing.

(p) “Level Four” – Appeal to the Florida Healthy Kids Corporation Board – If the complainant is not satisfied with the Florida Healthy Kids Corporation Dispute Review Panel’s decision, the complainant can request a review of the decision by the Florida Healthy Kids Corporation Board of Directors at its next regularly scheduled meeting. The complainant must submit a written statement and supporting documentation with the record of the Dispute Review hearing. No verbal testimony will be considered. The Board of Directors shall take one of three actions:

1. Accept the Dispute Review Panel’s decision. This acceptance will be considered final for this segment of the review process;

2. Modify the Dispute Review Panel’s decision. All modifications will be considered final for this segment of the review process; or

3. Send the dispute back to the Dispute Review Panel for further review as specifically directed by the Board of Directors.

(q) The Resolution Coordinator will prepare a final report comprising all information concerning the dispute review process to the Florida Healthy Kids Corporation Executive Director and Board of Directors. The Resolution Coordinator shall notify the complainant of the Florida Healthy Kids Corporation Board of Director’s decision in writing within ten (10) calendar days of the Florida Healthy Kids Corporation Board meeting. The written notification from the Florida Healthy Kids Corporation Board regarding the Board’s decision shall also notify the complainant of the Florida KidCare Grievance Process.

(r) If a complainant is dissatisfied with the decision made at Level Four of the Florida KidCare Program Dispute Review and if the Florida KidCare Program Dispute Review Process has been completed, a grievance can be filed with the Florida KidCare Grievance Committee.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New_________.

 

59G-14.005 Florida KidCare Grievance Committee.

(1) The Florida KidCare Grievance Committee shall review and resolve grievances related to the Florida KidCare Program when all four levels of resolution through the Florida KidCare Dispute Review Process have been completed. Grievances heard by the Florida KidCare Grievance Committee shall include eligibility and enrollment matters relating to Florida Healthy Kids, MediKids or the Children’s Medical Services Network. Grievances involving more than one Florida KidCare Program will also be addressed by this committee. Disputes involving more than one Florida KidCare partner shall be immediately referred to the KidCare Grievance Committee. The following provisions apply to the Florida KidCare Grievance Committee:

(a) The Florida KidCare Grievance Committee consists of one representative from each of the following Florida KidCare partners, appointed by their respective agency. The fifth representative shall be the Project Director (or designee) of the Florida Covering Kids and Family Coalition.

1. Agency for Health Care Administration – (MediKids)

2. Department of Children and Family Services –  (Medicaid for Children).

3. Department of Health – (Children’s Medical Services Network).

4. Florida Healthy Kids Corporation – (Healthy Kids).

5. A representative of the Florida Covering Kids and Family Coalition.

(b) The Agency for Health Care Administration’s representative shall serve as the committee chair. The committee members shall select a co-chair, who will serve as the chair in the absence of the Agency’s representative.

(c) Staff from the Agency for Health Care Administration will serve as the administrative staff for the Florida KidCare Grievance Committee. The duties and responsibilities of the administrative staff include: evaluating the Florida KidCare Dispute Review procedures to determine if the complaint was properly resolved for each grievance presented for the committee’s review; preparation of grievance committee correspondence and documents; preparation and distribution of grievance committee minutes; and provision of all necessary information, including the grievance committee’s final decision to all contributing parties.

(d) The committee shall meet the second Monday of each month. The committee shall not meet if there are no pending grievances. Additional meetings to resolve a grievance will be scheduled, as needed. If further documentation is necessary for the committee to reach a decision, the complainant will be notified in writing. When a grievance decision is rendered by the committee, the complainant will be notified in writing within ten (10) calendar days.

(e) All committee members are required to be present or participate by telephone conference call on grievance decisions. Grievance review documents will be provided to committee members prior to committee meetings. If a committee member is not available to attend the committee meeting, a designated representative authorized to vote on behalf of the respective agency may participate as a substitute member. Anyone requiring special accommodations to participate in the committee meetings is asked to advise the Florida KidCare Grievance Committee administrative staff one week in advance of the day of the scheduled committee meeting.

(f) Unless otherwise specified, committee meetings will be held in Tallahassee at the Agency for Health Care Administration’s headquarters offices. It is not mandatory for the grievant to be a participant at the grievance meeting(s). The grievant or authorized representative may attend the grievance committee meeting(s) at their own expense. If it is inconvenient for the grievant or representative to travel to the grievance committee meeting, the Agency for Health Care Administration staff will arrange for the grievant to participant by telephone conference call from the area Medicaid office closest to the grievant’s place of residence.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New________.

 

59G-14.006 Florida KidCare Grievance Procedures.

(1) If the grievant is dissatisfied with the action taken by the Florida Healthy Kids Board of Directors, the grievant can submit a written request for the Florida KidCare Grievance Committee to review the grievance. The grievant’s written request must be submitted to the Agency for Health Care Administration within ten (10) calendar days of the date appearing on the Florida KidCare Dispute Review Level Four final decision notice. In the event a grievant is unable to submit a request in writing, assistance will be provided by the Agency for Health Care Administration staff. If the request is not received within ten (10) calendar days, the Florida KidCare Grievance Committee reserves the right to decline the request. All grievances must be sent to: Florida KidCare Grievance Committee, Bureau of Medicaid Services, 2727 Mahan Drive, MS #20, Tallahassee, FL 32308.

(2) When the written grievance request is received, the Agency for Health Care Administration staff will send a letter of acknowledgement to the grievant explaining the procedures of the grievance process within five (5) calendar days of receipt of the request for a grievance. The acknowledgement letter will include: the Florida KidCare Formal Grievance Form, AHCA Med-Serv Form 009, August 2007, one page; an Appointment of Representation Form, AHCA Med-Serv Form 017, August 2007; and the Authorization for the Use and Disclosure of Protected Health Information Form, AHCA Med-Serv Form 018, August 2007 which are incorporated by reference. In the event a grievance is submitted by someone other than the custodial parent or legal guardian, the Agency for Health Care Administration staff shall require the custodial parent or legal guardian to complete the forms referenced in this paragraph.

(3) The Agency for Health Care Administration staff will review the grievance and determine if the Florida Healthy Kids Corporation used appropriate measures as outlined in this rule when conducting the Dispute Review Process. When necessary, the relevant Florida KidCare partner of coverage will be contacted and asked to provide information associated with the case. If the initial eligibility or enrollment decision is correct and the Florida Healthy Kids Corporation followed the dispute review process outlined in this rule, the complainant will be notified in writing that the decision determined during the Florida KidCare Dispute Review Process shall remain unchanged.

(4) If it is determined that further remedy is warranted, the committee shall be required to hear the grievance. The committee shall discuss the grievance at its next regularly scheduled monthly meeting.

(5) The committee members will review all pertinent information prior to the scheduled meeting. During the scheduled meeting the committee members will discuss and assess the grievance and any supplemental information provided. The following considerations apply to the Florida Grievance Review Process:

(a) The grievant shall be given an adequate opportunity to examine the contents of the Florida KidCare Dispute Review file and all other relevant documents and records prior to the Florida KidCare Grievance Committee meeting. The grievant can request and receive a complete copy of the materials provided to the Florida KidCare Grievance Committee prior to the meeting at no charge.

(b) The grievant can represent themselves at the grievance meeting or be assisted by an authorized representative.

(c) The grievant shall be asked to provide the names and affiliations of any additional attendees he or she would like to have present during the grievance meeting prior to the scheduled grievance meeting.

(6) The committee members will verbally vote to render a decision. The committee’s decision shall be based on a majority vote. The decision of the committee is final and all KidCare partners will abide by such decision. The grievant will be notified in writing of the committee’s decision within ten (10) calendar days of the Florida KidCare Grievance Committee meeting.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New________.

 

59G-14.007 Health Services Complaints and Disputes.

(1) Health services complaints involve delay, denial, reduction, or termination of health services or payment for receipt of health services. When a health care service complaint warrants an expedited time frame, the relevant Florida KidCare Program shall be responsible for ensuring the review is conducted within the time frames outlined in 42 CFR s. 457.1160 (b) (2).

(2) Each Florida KidCare Program entity has developed their own particular process for resolving health service complaints and disputes.

(a) Florida Healthy Kids Corporation – The Resolution Coordinator shall contact the health services provider and request that the health services provider accept the complainant’s written request to Florida Healthy Kids Corporation regarding a dispute as the initial step in the health services provider’s dispute review process. With the complainant’s consent, the Resolution Coordinator will forward any pertinent information to the health services provider. The Resolution Coordinator shall request the health services provider to respond to the complainant’s dispute request in accordance with the time frames stated in its complaint or grievance process and 42 CFR s. 457.1160. The Resolution Coordinator shall follow up with the health services provider within twenty (20) calendar days of receipt of the complainant’s dispute request to confirm appropriate action has been taken. The health services provider’s action shall be documented including the date and time any action was taken.

(b) MediKids – The MediKids policy staff will refer the complainant to the appropriate health care provider for resolution of the dispute; or if the complainant requests, the MediKids policy staff will make a referral to the appropriate health care provider. When the complainant’s child(ren) is enrolled in a managed care organization, the complainant will be referred to the managed care organization for resolution of the dispute. When the complainant’s child(ren) is enrolled with a MediPass provider, the complainant will be referred to the area Medicaid office for assistance with the dispute process. The MediKids staff shall request the health services provider respond to the complainant’s dispute request in accordance with the time frames stated in the providers complaint or grievance process and 42 CFR s. 457.1160.

(c) Children Medical Services Network – The Children’s Medical Services Network staff will refer health services complaints to the relevant Children’s Medical Service area office Nursing Director. The Children’s Medical Services Network staff shall request that the complainant’s dispute request is completed in accordance with the time frames stated in 42 CFR s. 457.1160.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New________.

NAME OF PERSON ORIGINATING PROPOSED RULE: Angela Wiggins
NAME OF SUPERVISOR OR PERSON WHO APPROVED THE PROPOSED RULE: Andrew Agwunobi, M.D., Secretary
DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 27, 2007
DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: November 3, 2006