Appeals of Adverse Actions for Medicaid Non-State Operated

3060 - Appeals of Adverse Actions for Medicaid Non-State Operated NFs (Non-State Operated) and ICFs/IID (Not Applicable to Federal Terminations of Medicaid Facilities) (Rev. 92, Issued, 11-22-13, Effective: 11-22-13, Implementation: 11-22-13) Denials, terminations, cancellations, and denials of payment for new admissions and other adverse actions to facilities participating in Medicaid-only are State administrative actions and decisions. State appeal procedures must be made available to facilities in cases of nonrenewal, denial, cancellation, or termination of the provider agreement. It is up to the State to designate the office or official having authority to hear and decide Medicaid appeals. Although the State retains considerable flexibility in developing its own appeal procedures, the procedures for an ICF/IID must at a minimum provide for an evidentiary hearing either before or within 120 calendar days after the effective date of the adverse action. The State must also provide an informal reconsideration prior to taking adverse action if it elects to provide a full evidentiary hearing after the effective date of the adverse action for an ICF/IID (42 CFR 431.150 through 431.154). If a NF requests a hearing on a denial or termination of its provider agreement, the request does not delay the adverse action and the hearing need not be completed before the effective date of the action. However, a NF is entitled to a hearing before a CMP is collected (see §7526). NOTE - In the procedures for denial of payment for new admissions for ICFs/IID (see §3060.C), a post-termination hearing is not a permitted option. The State must provide an informal hearing before the effective date of the denial of payments for new admissions. Consequently, reconsideration is not appropriate for these appeals. 3060A - Informal Reconsideration (Rev. 1, 05-21-04) The State may develop and implement its own reconsideration proceedings. However, the process must include: • Timely notice of the reason for the action; • A reasonable opportunity for the provider/supplier to refute those reasons in writing; and • A written decision prior to the effective date of the adverse action. 3060B - Evidentiary Hearing (Rev. 1, 05-21-04) The evidentiary hearing must include: • Timely written notice to the provider/supplier of the findings upon which the termination or denial is based, and disclosure of the evidence on which the decision is taken; • An opportunity for the provider/supplier to appear before an impartial decision maker to refute the basis for the decision; • An opportunity for the provider/supplier to be represented by counsel or another representative; • An opportunity for the provider/supplier or its representatives to be heard in person, to call witnesses, and to present documentary evidence; • An opportunity for the provider/supplier to cross-examine witnesses; and • A written decision by an impartial decision-maker, setting forth the reasons for the decision and the evidence on which the decision is based. 3060C - Informal Reconsideration (Applies to ICFs/IID for Denial of Payment for New Admissions Only) (Rev. 92, Issued, 11-22-13, Effective: 11-22-13, Implementation: 11-22-13) The informal hearing process must include: • Timely notice of the reason for the action; • A reasonable opportunity for the provider/supplier to present in writing or in person reasons for its disagreement; • An opportunity for the provider/supplier or its representatives to be heard in person and to present documentation; and • A written decision by an impartial decision maker, prior to the effective date of the denial of payment, setting forth the reasons for the determination. An evidentiary hearing does not follow the informal hearing. 3060D - Judicial Review (Rev. 1, 05-21-04) Federal regulations do not provide for judicial review of these appeals proceedings. State law governs judicial review. 3060E - Impartial Decision Maker (Hearing Officer) (Rev. 1, 05-21-04) The State has flexibility in selecting individuals to conduct the reconsideration and hearing proceedings. However, in both proceedings, certain individuals should be excluded from serving as decision-makers. In reconsideration proceedings, the SA, as well as other persons directly involved in gathering and providing evidence upon which the adverse action is based, is ineligible to make decisions. (One person should not be both witness and judge.) However, the person who made the original determination based on the surveyors’ findings is not ineligible to decide the reconsideration. If the decision is originally made at the highest level, the appeal decision should also be made there. However, if a regional supervisor makes the original decision, have someone higher in authority review the appeal. In administrative hearings, all persons directly involved in either the survey or the reconsideration process are ineligible for reasons of impartiality. Prospective Payment System (PPS)