Resolving Disputes

1
Resolving Disputes

• Training for Employment Networks and State
  Vocational Rehabilitation Agencies
  
• January 2007

2
Module 8

• Resolving Disputes

3
Learning Objectives

• Describe the process for resolving disputes
  between Employment Networks (EN) or State
  Vocational Rehabilitation (VR) Agencies, and
  MAXIMUS
• Describe the process for resolving disputes
  between beneficiaries and ENs
  
• Describe the process for resolving disputes
  between ENs and State VR Agencies
  

4
Learning Objectives

• Describe the process for resolving disputes
  between beneficiaries and State VR Agencies
  
• Describe the process for resolving payment
  disputes between ENs and the Social Security
  Administration

5
Disputes Between Employment Networks or State
Vocational Rehabilitation Agencies and MAXIMUS
6
MAXIMUS Dispute Resolution Process

• ENs and VRs can use MAXIMUS internal procedures
  to resolve disputes
  
• If process does not result in a mutually
  agreeable solution, dispute is forwarded to the
  Social Security Administration within 20 days of
  receiving the following
• Description of disputed issue
• Summary of ENs/VRs and MAXIMUS position
• Description of solutions proposed by both
  parties
  

7
MAXIMUS Dispute Resolution Process

• Once referred to the Social Security
  Administration, their decision is final
  
• Process does not apply to disputes involving
  payment requests or reimbursements
  
• State VR Agency serving beneficiaries under the
  the traditional cost reimbursement system will be
  resolved under existing regulations governing
  payment request disputes

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Disputes Between Beneficiaries and ENs
9
EN Dispute Process Requirements

• EN is required to provide copy to Beneficiary
  each time an IWP is signed
  
• Process should inform the beneficiary of the
  following
  
• The right to refer a dispute to MAXIMUS
• The right to refer a dispute to the Social
  Security Administration, if MAXIMUS resolution is
  dissatisfactory
  
• The availability of assistance from the State
  Protection Advocacy (PA) system
  

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Steps in the EN and Beneficiary Dispute
Resolution Process

• Beneficiary seeks solution through ENs internal
  grievance process
  
• If unresolved, the beneficiary or the EN may seek
  resolution from MAXIMUS
  
• If still unresolved, the beneficiary or the EN
  may seek resolution from the Social Security
  Administration

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MAXIMUS Role in Resolving EN or Beneficiary
Disputes

• When escalating an issue to MAXIMUS for review,
  the EN has 10 business days to submit all
  relevant information
  
• A full review will be conducted by MAXIMUS with
  recommendation for a resolution
  
• A written recommendation is provided by MAXIMUS
  to the EN and beneficiary within 20 working days
  
  
• Either party that is dissatisfied with the
  results can request a review by the Social
  Security Administration Office of Employment
  Support Programs

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Required Elements of the Request to MAXIMUS

• Description of disputed issues
• Summary of the beneficiarys position related to
  each disputed issue, prepared by the beneficiary
  or his/her designee
  
• Summary of the ENs position related to each
  disputed issue, prepared by the EN
  
• Description of any solutions proposed by the EN ,
  including why the beneficiary rejected the
  solutions

13
Social Security Administrations Role in
Resolving EN and Beneficiary Disputes

• Request for Social Security Administrations
  review must be in writing and forwarded to
  MAXIMUS within 15 days of receipt of MAXIMUS
  recommendation
• Within in 10 working days, MAXIMUS must forward
  the request to the Social Security Administration
  
  
• The Social Security Administrations
  recommendation is final
  
• If either party is dissatisfied with the final
  recommendation, either party has the right to
  terminate the relationship with the other party
  

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Required Elements of the Request to the Social
Security Administration

• Copy of the beneficiary IWP
• Information on the disputed issue
• Any relevant evidence
• Detailed discussion of the facts, evidence, and
  other issues related to the dispute
  
• Supporting documentation for MAXIMUS
  recommendation including statements from parties
  and excerpts from relevant statutes or
  regulations and
• Conclusions and recommendations from MAXIMUS

15
Disputes Between Employment Networks and State VR
Agencies
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Steps in the EN and VR Agency Dispute Resolution
Process

• Agreement between both entities should include
  procedures for dispute resolution
  
• If no procedures listed in agreement, resolution
  should follow procedures as addressed under state
  law or administrative procedures
  
• If state law or administrative procedures do not
  address issue, either party may contact MAXIMUS
  for a suggested resolution

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Required Elements of the Request to MAXIMUS

• The request should be in writing and include the
  following
  
• elements
• Copy of the agreement,
• Information regarding dispute, and
• Information regarding the position of both the EN
  and the State VR Agency
  

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MAXIMUS Role in Resolving EN and State VR Agency
Disputes

• Following receipt of request, MAXIMUS has 20
  calendar days to recommend a resolution to the
  dispute
  
• If either party is disagrees with the MAXIMUS
  recommendation, then either entity may contact
  the Social Security Administration within 30
  calendar days after receiving MAXIMUS
  recommendation for another review

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Disputes Between Beneficiaries and State VR
Agencies
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Rehabilitation Act of 1973

• Procedures in the Rehabilitation Act of 1973, as
  amended, apply to any Ticket-holder assigned to
  the State VR Agency
  
• Requires State VR Agency to provide description
  of services provided through Client Assistance
  Program (CAP)
  
• Provides opportunity to resolve disputes using
  formal mediation services or impartial hearing
  process

21
Payment Disputes Between EN or State VR Agency
Functioning as EN and the Social Security
Administration
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EN Payment Dispute Resolution with Social
Security Administration

• If an EN, other than a State VR Agency, has a
  payment dispute, it is resolved through dispute
  resolution process in ENs Agreement (the Request
  for Proposal)
• If State VR Agency, functioning as an EN, has
  payment dispute under EN payment system, the
  State VR Agency may make a written request for
  reconsideration within 60 days of receiving
  notice of the Social Security Administrations
  decision

23
The State VR Agency Functioning as EN Payment
Dispute Process

• State VR Agency sends the request to MAXIMUS
• Then MAXIMUS forwards the request to the Social
  Security Administration for reconsideration and
  recommendation
  
• The Social Security Administration makes decision
  and notifies the State VR Agency of its decision
  in writing
  
• There can be no appeal of any Social Security
  Administration decision that affects a
  beneficiarys entitlement or eligibility for
  benefits, despite the decisions effect on the
  ENs payment

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Appeals to the Social Security Administration
Payment Decision

• Only the beneficiary or his representative can
  appeal the decision
  
• However, the EN can provide evidence that might
  support a change in the Social Security
  Administration
  

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MAXIMUS Role in the Dispute Resolution Process

• Ensure that discrete and comprehensive records
  are maintained by the panel of Ticket staff to
  mediate disputes
  
• Provide assistance to the Social Security
  Administration in the investigation and
  resolution of issues
  
• Update the MAXSTAR system with detailed
  information about disputes between parties
  
• Maintain complete records of all payment history,
  correspondence, telephone contact, and other
  communications with each EN

26
Resolving Disputes

• Training for Employment Networks and State
  Vocational Rehabilitation Agencies
  
• January 2007