Common use of Risk Adjustment Appeals Clause in Contracts

Risk Adjustment Appeals. The MCO may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two weeks of notification of the new 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 factor based on encounter data submitted in a timely manner.‌ 4.9.1 If the MCO appeals under this section, the STATE shall continue to pay the MCO the MCO’S subsequent quarter’s risk factor until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’S risk factor, the STATE shall adjust the MCO’S subsequent rates to correct the miscalculation. 4.9.2 The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome. 4.9.3 The MCO and the STATE shall work together to develop a review mechanism to ensure that this section of the Contract is accurately implemented.

Risk Adjustment Appeals. The MCO may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two weeks of notification of the new 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 ’s risk factor based on encounter data submitted in a timely manner.‌manner as required by section 3.5.1. 4.9.1 (A) If the MCO appeals under this section, the STATE shall continue to pay the MCO the MCO’S ’s subsequent quarter’s risk factor until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’S ’s risk factor, the STATE shall adjust the MCO’S ’s subsequent rates to correct the miscalculation. 4.9.2 (B) The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome. 4.9.3 (C) The MCO and the STATE shall work together to develop a review mechanism to ensure that this section of the Contract is accurately implemented.

Risk Adjustment Appeals. The MCO may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two six weeks of notification of the new 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 ’s risk factor based on encounter data submitted in a timely manner.‌manner as required by section 3.5.1. 4.9.1 (A) If the MCO appeals under this section, the STATE shall continue to pay the MCO the MCO’S ’s subsequent quarter’s risk factor until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’S ’s risk factor, the STATE shall adjust the MCO’S ’s subsequent rates to correct the miscalculation. 4.9.2 (B) The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome. 4.9.3 (C) The MCO and the STATE shall work together to develop a review mechanism to ensure that this section of the Contract is accurately implemented.

Risk Adjustment Appeals. The MCO may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two weeks of notification of the new 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 ’s risk factor based on encounter data submitted in a timely manner.‌manner as required by section 3.5.1.‌ 4.9.1 (A) If the MCO appeals under this section, the STATE shall continue to pay the MCO the MCO’S ’s subsequent quarter’s risk factor until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’S ’s risk factor, the STATE shall adjust the MCO’S ’s subsequent rates to correct the miscalculation. 4.9.2 (B) The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome. 4.9.3 (C) The MCO and the STATE shall work together to develop a review mechanism to ensure that this section of the Contract is accurately implemented.

Risk Adjustment Appeals. The MCO may appeal to the STATE the following quarter’s risk factor. Any appeal of risk factors must be filed with the STATE within two weeks of notification of the new 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 factor based on encounter data submitted in a timely manner.‌manner. 4.9.1 If the MCO appeals under this section, the STATE shall continue to pay the MCO the MCO’S subsequent quarter’s risk factor until the appeal is resolved. If on appeal, the STATE is found to have miscalculated the MCO’S risk factor, the STATE shall adjust the MCO’S subsequent rates to correct the miscalculation. 4.9.2 The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome. 4.9.3 The MCO and the STATE shall work together to develop a review mechanism to ensure that this section of the Contract is accurately implemented.