02-031 C.M.R. ch. 380, § 6 - APPEALS

Pursuant to 24-A M.R.S.A. §§4303-A(1) and 4303-A(4), a carrier shall establish a process that affords a provider the opportunity to review and dispute its provider profiling result within 30 days after being provided with its provider profile. The appeal process must:

1. Afford the provider the opportunity to correct material errors, submit additional information for consideration, and seek review of data and performance ratings;

2. Afford the provider the opportunity to review any information or evaluation prepared by a third party and used by the carrier as part of its provider profiling program. However, if the third party provides a right to review and correct that data, any appeal from the carrier's determination pursuant to this paragraph is limited to whether the carrier accurately portrayed the information and not to the underlying determination made by the third party; and

3. Allow the provider to request reconsideration of its provider profiling result and submit supplemental information, including information demonstrating any computational or data errors.

4. In order to avoid unnecessary duplication of effort, the appeal process established by the carrier to afford the provider an opportunity to review and dispute its provider profiling result may incorporate the requirements of Section 5, Subsections 3 and 4, except that the carrier must allow for a separate appeal of its response to the provider's request for clarification and correction under Section 5, Subsections 3 and 4.

Notes

02-031 C.M.R. ch. 380, § 6