Common use of EW Risk Adjustment Appeals Clause in Contracts

EW Risk Adjustment Appeals. The MCO may appeal to the STATE the following year’s risk score. Any appeal of risk scores must be filed with the STATE within six weeks of notification of the risk factors. The basis for any appeal by the MCO under this section shall be limited to whether or not the STATE correctly calculated the MCO’s risk score based on encounter data submitted in a timely manner as required by section 3.7.1. The risk score appeal must contain a succinct explanation of why the MCO finds the scores incorrect, with supporting data sufficient to allow the STATE to evaluate the appeal in a timely fashion. If the MCO appeals under this section, the STATE shall proceed with paying the MCO the MCO’s risk score until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’s risk score, the STATE shall adjust the MCO’s subsequent rates to correct the miscalculation. The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.

EW Risk Adjustment Appeals. The MCO may appeal to the STATE the following year’s risk score. Any appeal of risk scores must be filed with the STATE within six weeks of notification of the risk factors. The basis for any appeal by the MCO under this section shall be limited to whether or not the STATE correctly calculated the MCO’s risk score based on encounter data submitted in a timely manner as required by section 3.7.1. The risk score appeal must contain a succinct explanation of why the MCO finds the scores incorrect, with supporting data sufficient to allow the STATE to evaluate the appeal in a timely fashion. fashion.‌ If the MCO appeals under this section, the STATE shall proceed with paying the MCO the MCO’s risk score until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’s risk score, the STATE shall adjust the MCO’s subsequent rates to correct the miscalculation. The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.