Due Process Protection

Due Process Protection A. The Division of Medicaid and the case management agencies are responsible for operating a dispute resolution process separate from a fair hearing process. The Division of Medicaid has the final authority over any dispute. 1. The types of disputes addressed by an informal dispute resolution process include issues concerning service providers, waiver services, and other issues that directly affect waiver services. 2. At the initial assessment, the case management agency must provide written notice to inform the beneficiary/representative of the specific criteria for the dispute, complaint/grievance, and hearing processes. B. The Division of Medicaid provides an opportunity to request a Fair Hearing to beneficiaries: 1. Who are not given the choice of home and community-based services as an alternative to the institutional care, 2. Who are denied the service(s) of their choice or the provider(s) of their choice, or 3. Whose services are denied, suspended, reduced, or terminated. C. Notice of Action 1. The case management agency must provide the beneficiary with a Notice of Action (NOA) via certified mail as required in 42 C.F.R. §431.210. 2. The NOA must include: a) A description of the action the provider has taken or intends to take, b) An explanation for the action, c) Notification that the person/representative has the right to file an appeal, d) Procedures for filing an appeal, e) Notification of person/representative’s right to request a Fair Hearing, f) Notice the person/representative has the right to have benefits continued pending the resolution of the appeal, and g) The specific regulations or the change in federal or state law that supports or requires the action