Definitions

Definitions The Division of Medicaid defines: A. Case Record as all documents relevant to the administration of an appeal, including but not limited to all correspondence, applications, medical records and decisions, and past appeals. B. Course of Treatment as a planned program of one or more services or supplies. C. Grievance as an expression of dissatisfaction submitted orally or in writing about any matter, including but not limited to the quality of services provided, rudeness from a Division of Medicaid employee, unfair treatment, or failure to respect the applicant or beneficiary’s rights. D. Local Hearing or Reconsideration as a hearing held at the Division of Medicaid Regional Office from which the decision the applicant or beneficiary wishes to appeal was generated. E. State Hearing or Fair Hearing as an orderly, but informal meeting in which an applicant or beneficiary or his/her representative is afforded an opportunity to address an impartial hearing officer for the purpose of presenting oral testimony and/or evidence of the individual’s entitlement to medical assistance and services. 1. The applicant or beneficiary has the right of confrontation and cross-examination. 2. A fair hearing is a de novo hearing which means the determination process starts over from the beginning. A new determination of the applicant or beneficiary’s eligibility is made based on all the evidence that can be secured, without regard to whether the evidence was available at the time the regional office took action. Thus, the process is not essentially different from a determination of eligibility. 3. This hearing is conducted by the Division of Medicaid’s Central Office. F. Hearing Officer as the presiding officer appointed by the Executive Director or the Executive Director’s designee to conduct administrative hearings within the guidelines stated in this chapter. The Hearing Officer may: 1. Issue subpoenas, 2. Administer oaths, 3. Compel attendance and testimony of witnesses, 4. Require the production of books, papers, documents, and other evidence required, 5. Take depositions, 6. Preserve and enforce order during the administrative hearing, 7. Call informal, status, or pre-hearing conferences, 8. Invite stipulations between the parties, and 9. Do all things conformable to law and Medicaid regulations that may be necessary to enable the Hearing Officer to effectively perform the Hearing Officer’s duties. G. A legal representative or representative as the applicant or beneficiary’s authorized representative, an attorney retained to represent the applicant or beneficiary, a paralegal representative with a legal aid service, the parent of a minor child if the beneficiary or appellant is a child, a legal guardian or conservator or an individual with power of attorney for the applicant or beneficiary. 1. The applicant or beneficiary may be represented by anyone they designate. 2. If the applicant or beneficiary elects to be represented by someone other than a legal representative, they must designate the person in writing. 3. If a person, other than a legal representative, states that the applicant or beneficiary has designated them as the applicant or beneficiary’s representative, and the individual has not provided written verification to this effect, the regional office will ask the individual to obtain written designation from the applicant or beneficiary. H. Final Decision as the decision rendered by the Executive Director at the end of the hearing process, subject to appeal only through judicial review. I. Judicial Review as the relief available to an applicant or beneficiary after the Division of Medicaid has rendered its final decision. Final decisions by the Division of Medicaid may be appealed to the court of proper jurisdiction for Judicial Review. J. Advance Notice Period as the time in which the Division of Medicaid must send a notice before the date of an action, except when advance notice is impossible, or in cases of probable fraud. K. Adverse Action as a decision rendered by the Division of Medicaid denying or reducing an applicant or beneficiary’s coverage or desired treatment. An applicant or beneficiary will receive written notice of an adverse action and be able to file for an appeal after receipt of this notice.