Following are step-by-step instructions about how to read and interpret the appeals information:

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Earl Pierce
6 years ago
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1 QiRePort PROVIDER INTERFACE: READING APPEALS/MAINTENANCE OF SERVICE INFORMATION FOR YOUR CLIENTS WHO HAVE SUBMITTED AN APPEAL (3/24/11) The new appeals feature of QiReport allows providers to: Receive electronic notification of the date that the agency can begin Maintenance of Service for a client who has entered an appeal Receive notification of the outcome of an appeal, including cases where the denial was upheld or the appeal was withdrawn by the recipient Receive electronic specific information about the resolution of the appeal, including resolution date, settlement, effective date of the settlement, and cases that were withdrawn. Respond to appeal settlement referrals electronically, instead of by fax. Following are step-by-step instructions about how to read and interpret the appeals information: 1. A referral for the recipient who has entered an appeal will appear on the Referrals screen with the Notification Type, MOS (Maintenance of Service): MOS 3/21/

2 2. Click on the recipient s underlined name to open the Recipient Summary page. If the recipient has entered an appeal, this page will display the date the recipient entered the appeal, the status of the appeal, and MOS hours authorized (highlighted below). 815 N. MAIN ST FEMALE Change of Status The Appeal Resolution section (marked with red bracket) will appear blank until CCME receives notice that the appeal has been resolved.

3 3. Scroll to the bottom of the Recipient Summary page to respond to the referral. Change of Status 0 Select a Referral Decision response from the drop-down menu. Then click Save. *Please note: providers who are registered to use the Provider Interface of QiReport do NOT need to send the referral decision by fax to CCME. Your referral response will be entered electronically into QiReport when you follow the Referral Decision steps above. 4. If you accept the referral, the recipient s name will appear on the Accepted (last 60 days) screen: The new settlement hours will appear under the Hours column.

4 5. Once CCME has received notice that the appeal has been resolved, the recipient s name will again appear on the Referrals page with the Notification Type, Appeal Resolution: Appeal Resolution 3/21/

5 6. Click on the recipient s underlined name to open the Recipient Summary Page to view the outcome of the appeal: Example outcome: appeal resulted in a settlement 815 N. MAIN ST. Female You can view the appeal outcome, as well as the settlement hours and the effective date of the new settlement hours (highlighted). In this example, the appeal resulted in a negotiated settlement of 36 hours. MOS hours will end, and the authorization for the new hours will go into effect on 3/11/11. Example outcome: Appeal Dismissed 815 N. MAIN There is no change to the 22 hours authorized by the IA. The maintenance of service authorization will end, and the authorization for 22 hours will go into effect on 3/7/11.

Example outcome: Final Agency Decision (FAD)-Affirmed 815 N. MAIN 704--999-9999 A FAD-Affirmed outcome means that Medicaid agreed with the Administrative Law Judge s decision in the case.

6 Example outcome: Final Agency Decision (FAD)-Affirmed 815 N. MAIN A FAD-Affirmed outcome means that Medicaid agreed with the Administrative Law Judge s decision in the case. In this example, the denial was upheld. Example outcome: Final Agency Decision (FAD)-Rejected 815 N. MAIN A FAD-Rejected outcome means that Medicaid disagreed with the Administrative Law Judge s decision in the case. In this example, the Medicaid reviewer approved 28 hours as the final settlement.

7 7. Scroll to the bottom of the Recipient Summary page to respond to the referral and make a selection from the Referral Decision drop-down menu. Then, click Save. *Please note: providers who are registered to use the Provider Interface of QiReport no longer need to send the referral decision by fax to CCME. Your referral response will be recorded electronically by QiReport when you follow the Referral Decision steps above. 8. To view the Appeal Settlement letter, click on the Accepted (last 60 days) link Then, click the [letter] link under the Notification Letter column to open the PDF document. Not Available indicates that the Recipient Notice hasn t yet been processed.

PCS Provider Use of QiRePort. September 2010

PCS Provider Use of QiRePort. September 2010 PCS Provider Use of QiRePort September 2010 What is QiReport? Web-based information system to support PCS independent assessments Helps collect, store and communicate assessment results Secure site to