New DOH Policies on Contracting as a Fiscal Intermediary and Interim Guidance on Appeal Notices
The Department of Health (DOH) released two new managed care policies.
1.) MLTC Policy 15.04: Interim Guidance for MLTC Partial Capitation Appeal Notices
This policy clarifies that within Section 1.B. of Appendix K of the Partial Capitation Model Contract, there are four required notice templates relating to Expedited and Standard Appeals. This new policy describes how these notices will be affected by the elimination of the exhaustion requirement for internal appeals. This refers to MLTC Policy15.03: End of Exhaustion Requirement for MLTC Partial Capitation Plan Enrollees. MLTC Policy 15.03 became effective in July 2015. MLTC Policy15.04 is effective immediately.
The four required notice templates are impacted by this new policy as follows:
Notice Template 1: Plans must send the enrollee a letter indicating the plan will not make a determination on the appeal because the appeal request was not submitted by the member within 60 business days. This reflects a change from 45 days to 60 days.
Notice Template 2: No Change
Notice Template 3: No Change
Notice Template 4: Major change as a result of elimating the intranal appeal exhaustion requirement.
The purpose of this policy is to clarify the conditions under which a Managed Care Organization (MCO) may sign an administrative agreement with a FI for the CDPAS. Please note FI organizations must apply for a discrete Medicaid provider ID number that is solely associated with its FI by completing the New York State Medicaid Enrollment Form available at the following link.
The policy clarifies that securing a contract with a LDSS is not necessary when contracting with a MCO. It further explains what a MCO must do if the MCO wants to become a FI.
The policy details all of the requirements in 18 NYCRR 505.28 that a FI must meet in the CDPAS regulations. Any FI that does not meet the requirments has 120 days grace period to become compliant with the regulations.
Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871