Reconsideration of MassHealth-assigned Case-mix Classification Rating

(A) A nursing facility may request reconsideration of MassHealth’s audit findings and of the case-mix classification rating assigned by MassHealth. All requests must state the facility's justification for the request for reconsideration and must contain documentation justifying the request for reconsideration. All documentation must be specific to the individual whose case-mix classification rating is under review. The request for reconsideration must be received by MassHealth within 30 days from the date that the nursing facility receives the audit findings from MassHealth. (B) If the nursing facility does not submit a request for reconsideration, the audit findings issued pursuant to 130 CMR 456.420(C) will constitute MassHealth’s final action. If the nursing facility requests reconsideration but does not comply with the requirements of 130 CMR 456.421(A), then MassHealth will deny the request for reconsideration for failure to make a timely request. In either case, MassHealth’s audit findings will constitute MassHealth’s final agency action and the nursing facility will have no right to an adjudicatory hearing pursuant to 130 CMR 456.421(C) because of its failure to exhaust its administrative remedies. (C) MassHealth will review a request for reconsideration, the accompanying documentation submitted in compliance with the requirements of 130 CMR 456.421(A), and any other documents MassHealth deems relevant and issue a final decision based on its review. The decision by MassHealth will be a determination of whether the nursing facility has met all the criteria for the case-mix classification item or items that are the subject of the reconsideration. The determination will be in writing, state the reasons for the determination, and inform the nursing facility of its right to file a Claim for Adjudicatory Hearing in accordance with 130 CMR 450.241: Hearings: Claim for an Adjudicatory Hearing. The Board of Hearings will decide the claim in accordance with 130 CMR 450.248: Medicaid Director’s Decision.