Common use of Risk Adjustment Appeals Clause in Contracts

Risk Adjustment Appeals. The MCO may appeal risk factors to the STATE. Any appeal of risk factors must be filed with the STATE within 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 risk factor based on encounter data submitted in a timely manner. 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 continue to pay the MCO using the MCO’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. The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.

Risk Adjustment Appeals. The MCO may appeal risk factors to the STATE. Any appeal of risk factors must be filed with the STATE within six weeks of notification of the new risk factors. The basis for any appeal by the MCO under this section shall be limited to‌ to whether or not the STATE correctly calculated the MCO’s risk factor based on encounter data submitted in a timely manner. 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 continue to pay the MCO using the MCO’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. The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.

Risk Adjustment Appeals. The MCO may appeal risk factors to the STATE. Any appeal of risk factors must be filed with the STATE within six weeks of notification of the new risk factors. The basis for any appeal by the MCO under this section shall be limited to‌ to whether or not the STATE correctly calculated the MCO’s risk factor based on encounter data submitted in a timely manner. 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. . (A) If the MCO appeals under this section, the STATE shall continue to pay the MCO using the MCO’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. . (B) The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.

Risk Adjustment Appeals. The MCO may appeal risk factors to the STATE. Any appeal of risk factors must be filed with the STATE within six weeks of notification of the new risk factors. The basis for any appeal by the MCO under this section shall be limited to‌ to whether or not the STATE correctly calculated the MCO’s risk factor based on encounter data submitted in a timely manner. 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 continue to pay the MCO using the MCO’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. The MCO and the STATE shall each pay half the cost of investigating and resolving the appeal, regardless of outcome.