Hearings: Consideration of a Claim for an Adjudicatory Hearing

(A) A timely claim must specifically identify each issue and fact in dispute and state the provider's position, the pertinent facts to be adduced at the hearing, and the reasons supporting that position. (B) If a matter has been referred to or is under investigation by the Attorney General’s Medicaid Fraud Division or other criminal investigation agency, or if a question of quality of care has been referred to a professional licensing board for investigation, the Board of Hearings, upon notice from the MassHealth agency, will postpone the hearing until the conclusion of such investigation and the final disposition of any criminal complaint, indictment, or order to show cause that ensues, or until the MassHealth agency notifies the Board to schedule the hearing. A provider may not request a postponement of the hearing under 130 CMR 450.243(B). (C) The Board of Hearings will grant a hearing only if the claimant demonstrates all of the following. (1) The claim was filed with the Board of Hearings and the MassHealth agency within the time limits set forth in 130 CMR 450.241. (2) There is a genuine and material issue of adjudicative fact for resolution. (3) The factual issues can be resolved by available and specifically identified reliable evidence as set forth in M.G.L. c. 30A, § 11(2). A hearing will not be granted on the basis of general allegations or denials or general descriptions of positions and contentions. 2. Administrative Regulations (4) The allegations of the provider, if established, would be sufficient to resolve a factual dispute in the manner urged by the provider. A hearing will not be granted if the provider’s submissions are insufficient to justify the factual determination urged, even if accurate. (5) Resolution of the factual dispute in the way sought by the provider is relevant to and would support the relief sought. (D) Failure to comply with the conditions of 130 CMR 450.243(C) may result in dismissal of the claim, at the discretion of the Office of Medicaid Board of Hearings. Dismissal of a claim, without a timely request to vacate, or an upheld dismissal following a timely request to vacate, is a final agency action reviewable pursuant to M.G.L. c. 30A. Dismissal of a noncompliant claim, and the request to vacate a dismissal, shall be governed as follows: (1) The appellant will be informed by written notice of the dismissal and of the procedures for requesting that the dismissal be vacated. (2) A request to vacate a dismissal must be in writing, must be signed by the appellant, and must demonstrate good cause for the appellant’s failure to comply with the conditions set forth in 130 CMR 450.243(C). (E) Notwithstanding 130 CMR 450.243(C) and (D), if there is no issue of adjudicative fact, but the provider has challenged the MassHealth agency’s interpretation or application of regulations or laws, argument concerning such challenges will be presented in memoranda and briefs.