When a provider disputes any of the facts specific to the findings at the initial review or the follow-up review, the provider must submit documentation to the PCR project director within five business days. The documentation should identify the indicators under dispute, the reason the provider believes the indicator should not have received the rating and any documentation to support the provider’s claim. The project director will review the documentation presented and will determine if changes need to be made in the results of the initial review. This should be completed within five business days of receiving the provider’s documentation. If the project director finds that the documentation supports the provider’s argument for changing a rating of an indicator, the review will be rescored, and the results will be issued with the amended score. The previous scores will be considered null and void. If the project director determines that the evidence presented does not support changing indicators, the project director will issue a report detailing the rationale applied and notify the provider and DDS/DDA personnel of this determination.
If, at the end of the PCR process, the provider disputes any of the facts specific to the findings of the PCR indicators after an appeal has been reviewed by the PCR project director, the provider will have five business days after receipt of the decision to submit a written appeal to DDS’s Quality Management Division (QMD). The written appeal must include documentation that details which indicators and documentation the provider is disputing, the reasons why the provider is disputing the documentation and any documentation that supports the provider’s claims.
The DDS Director of QMD will appoint a reviewer to review the appeal. The reviewer will evaluate the appeal and may request more information from the provider and/or the PCR Team or schedule a meeting with the involved parties to gather facts. The reviewer will make a recommendation to the QMD director.
Within 20 business days of receipt of the written appeal, the QMD Director will issue a determination in writing to the provider and PCR team. If the results of the PCR are changed, an amended report will be issued to all parties.
The appeal does not delay sanctions. If the provider failed the PCR for any service, the provider will be placed on the Do Not Refer list, enhanced monitoring will be initiated, notifications will be made to people receiving services and their support teams and a recommendation will be made to DHCF to terminate the Medicaid Provider Agreement. If the appeal results in a change in the rating and the provider is determined to be certified, the QMD Director will take immediate actions to rescind any applicable sanctions.