Beneficiary Appeals

Beneficiary Appeals A. The Division of Medicaid provides beneficiaries the opportunity to request a fair hearing in order to appeal decisions of: 1. Eligibility, 2. Denial, 3. Termination, 4. Suspension, or 5. Reduction of Medicaid covered services. B. If a decision is made to reduce, deny, suspend, or terminate covered services provided to a Medicaid beneficiary, and the beneficiary disagrees with the decision, the beneficiary and/or the beneficiary’s legal representative must request a hearing within thirty (30) days of the notice of adverse action. See Part 300, Chapter 2, Rule 2.7, All Hearing Requests, for more information. C. The Division of Medicaid is not required to grant a hearing if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all beneficiaries. D. When an ongoing Course of Treatment is at issue, services will be maintained at the previous level during the appeal process. E. The Division of Medicaid may deny or dismiss a request for any hearing if the beneficiary and/or legal representative: 1. Withdraws the request in writing, or 2. Fails to appear at a scheduled hearing without good cause. F. The case shall be heard by an impartial hearing officer. G. At the Hearing Officer’s discretion, the case will be evaluated by an appropriate independent review professional in the same or a similar specialty as would typically manage the case being reviewed, or another healthcare professional. In no case shall the review professional have been involved in the initial adverse determination. H. Before the hearing, the beneficiary and/or the beneficiary’s legal representative will be provided a copy of the case file that will be used at the hearing in support of the adverse decision. I. The hearing will be held by telephone unless, at the hearing officer’s discretion, it is determined that an in-person hearing is necessary. J. The final hearing decision shall be rendered by the Executive Director of the Division of Medicaid based solely on the evidence produced at the hearing and the case record. The Division of Medicaid must take final administrative action on a hearing within ninety (90) days from the date the initial appeal request was received.