Source: https://townhall.virginia.gov/L/ViewXML.cfm?textid=13664
Timestamp: 2020-02-17 19:33:27
Document Index: 228201828

Matched Legal Cases: ['§438', '§438', '§ 1915', '§ 50', '§ 38', '§ 438', 'art 431', 'art 438']

9/3/19 3:28 PM [latest] 7/19/19 12:28 PM 5/30/19 8:31 AM 5/7/19 3:02 PM
"Adverse benefit determination" means, consistent with 42 CFR 438.400, [ a determination by the participating plan, subcontractor, service provider, or Virginia Department of Medical Assistance Services that constitutes a (i) denial or limited authorization of a service authorization request, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (ii) reduction, suspension, or termination of a previously authorized service; (iii) failure to act on a service request; (iv) denial in whole or in part of a payment for a service; (v) failure by the participating plan to render a decision within the required timeframes; (vi) failure to provide services in a timely manner; (vii) denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities; or (viii) denial of an enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network any of the following: (i) the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial, in whole or in part, of payment for a service; (iv) the failure to provide services in a timely manner, as defined by the State; (v) the failure of an MCO, PIHP, or PAHP to act within the timeframes provided in §438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals; (vi) for a resident of a rural area with only one MCO, the denial of an enrollee's request to exercise his or her right, under §438.52(b)(2)(ii), to obtain services outside the network; or (vii) the denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities ] .
[ "Commonwealth Coordinated Care" or "CCC" means the program for the Virginia Medicare-Medicaid Financial Alignment Demonstration Model. ]
"Commonwealth Coordinated Care Plus program" or "CCC Plus" means the department's mandatory integrated care initiative for certain qualifying individuals, including dual eligible individuals and individuals receiving long-term services and supports (LTSS). The CCC Plus program includes individuals who receive services through nursing facility (NF) care or from [ the ] four [ of the department's five ] home and community-based services (HCBS) § 1915(c) waivers [ (the Alzheimer's Assisted Living (AAL) Waiver individuals are not eligible for the CCC Plus program) ] .
"Dual eligible" means a Medicare [ enrollee member ] who receives Medicare Parts A, B, and D benefits and also receives full Medicaid benefits.
"Effective date" means the date on which a participating plan's coverage begins for [ an enrollee a member ] .
[ "Enrollee" means an individual who has enrolled in a participating plan to receive services under CCC Plus.
"Enrollee appeal" means an enrollee's request for review of an adverse benefit determination. ]
"Enrollment period" means the time that [ an enrollee a member ] is actually enrolled in a participating plan.
[ "Expedited appeal" means the process by which the participating plan must respond to an appeal by an enrollee if a denial of care decision and the subsequent internal appeal by a participating plan may jeopardize life, health, or ability to attain, maintain, or regain maximum function. ]
"Final decision" means a written determination by a department hearing officer from an appeal of an [ informal evidentiary proceeding internal appeal decision ] that is binding on the department, unless modified during or after the judicial process.
"Handbook" means a document prepared by the MCO and provided to the [ enrollee member ] that is consistent with the requirements of 42 CFR 438.10 and the CCC Plus contract and includes information about all the services covered by that plan.
[ "Hearing" means an informal evidentiary proceeding conducted by a department hearing officer during which an enrollee has the opportunity to present the enrollee's concerns with or objections to the participating plan's internal appeal decision. ]
"Hearing officer" means an impartial decision maker who conducts evidentiary [ state fair ] hearings for [ enrollee member ] appeals on behalf of the department.
"Internal appeal" means [ a an oral or written ] request to the MCO by a member, a member's authorized representative, or a provider acting on behalf of the member and with the member's written consent [ , ] for review of a contractor's adverse benefit determination. The internal appeal is the only level of appeal with the MCO and must be exhausted by a member or deemed exhausted according to 42 CFR 438.408(c)(3) before the member may initiate a state fair hearing.
"Long-term services and supports" or "LTSS" means a variety of services and supports that (i) help elderly [ enrollees members ] and [ enrollees members ] with disabilities who need assistance to perform activities of daily living and instrumental activities of daily living to improve the quality of their lives and (ii) are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities.
[ "Medically complex" means those who have a complex medical or behavioral health condition and a functional impairment, or an intellectual or developmental disability. ]
"Medically necessary" or "medical necessity" means an item or service provided for the diagnosis or treatment of an enrollee's condition consistent with standards of medical practice and in accordance with Virginia Medicaid policy (12VAC30-130-600 et seq.) [ or ] EPSDT criteria (for those younger than 21 years of age) in accordance with 42 CFR 441 Subpart B (§§ 50 through 62), 42 CFR 438.210, and 42 CFR 440.230.
"Member" [ means the same as "enrollee." means an individual who has enrolled in a participating plan to receive services under CCC plus. ]
[ "Member appeal" means a member's request for review of an adverse benefit determination. ]
"Network provider" means a doctor, hospital, or other health care provider that participates or contracts with a participating plan and, as a result, agrees to accept a mutually-agreed upon payment amount or fee schedule as payment in full for covered services that are rendered to eligible [ enrollees members ] .
[ "Open enrollment" means the time frame in which members are permitted to change from one MCO to another without cause. ]
"Program of All-Inclusive Care for the Elderly" or "PACE" means the program in which the PACE provider provides the entire spectrum of health services (preventive, primary, and acute) and long-term services and supports to its [ enrollees members ] without limit as to duration or cost of services pursuant to 12VAC30-50-320 et seq.
"Provider appeal" means an appeal to the department filed by a Medicaid-enrolled or network service provider that has already provided a service to [ an enrollee a member ] and has received an adverse reconsideration decision regarding service authorization, payment, or audit result.
"State fair hearing" means the DMAS evidentiary hearing [ process ] as administered by the Appeals Division. [ A state fair hearing is conducted by a department hearing officer to allow a member the opportunity to present the member's concerns with, or objections to the participating plan's internal appeal decision. ]
"Withdraw" means a written request from the [ enrollee member ] or the [ enrollee's member's ] authorized representative for the department to terminate the [ enrollee member ] appeal.
12VAC30-120-610. CCC Plus mandatory managed care [ enrollees members ] ; enrollment process.
[ 2. Individuals enrolled in the Commonwealth Coordinated Care (CCC) program will transition to CCC Plus in January 2018, which is after the CCC program ends. ]
[ 3. 2. ] Non-dual eligible individuals who receive long-term services and supports through an institution, the CCC Plus waiver [ (formerly known as the EDCD and Technology Assisted waivers) ] , Building Independence waiver, Community Living waiver, and Family and Individual Supports waiver.
[ 4. Individuals enrolled in the department's Medallion Health and Acute Care Program (HAP), except individuals in the Alzheimer's Assisted Living (AAL) waiver; AAL is excluded from CCC Plus. ]
[ 5. 3. ] All individuals classified as aged, blind, or disabled (ABD) without Medicare and not receiving LTSS. [ The majority of these individuals are currently enrolled in Medallion and will transition to CCC Plus effective January 1, 2018. ]
[ 4. Individuals who qualify for and enroll under Medicaid expansion who have been identified as medically complex. ]
[ 6. Individuals who have any insurance purchased through the Health Insurance Premium Payment (HIPP) program, as defined in 12VAC30-20-205 and 12VAC30-20-210. ]
[ 1. Individuals enrolled in the Alzheimer's Assisted Living (AAL) waiver. However, individuals with Alzheimer's disease and persons with dementia will be included if they meet other eligibility requirements and are not enrolled in the AAL waiver. The AAL waiver will discontinue on June 30, 2018. At that time, individuals who were enrolled in the AAL waiver may become enrolled in the CCC Plus program if they meet the other eligibility requirements of the program. ]
[ 2. 1. ] Individuals enrolled in another DMAS managed care program (e.g., Medallion, FAMIS, and FAMIS MOMS).
[ 3. 2. ] Individuals enrolled in a PACE program.
[ 4. 3. ] Newborns whose mothers are CCC Plus [ enrollees members ] on their date of birth.
[ 5. 4. ] Individuals who are in limited coverage groups, such as:
b. Individuals enrolled in Plan First [ who do not meet eligibility criteria for Medicaid expansion ] .
[ c. Individuals enrolled in the Governor's Access Plan who do not meet eligibility criteria for Medicaid expansion. ]
[ 6. 5. ] Individuals enrolled in a Medicaid-approved hospice program at the time of enrollment. However, if an individual enters a hospice program while enrolled in CCC Plus, the member will remain enrolled in CCC Plus.
[ 7. 6. ] Individuals who live on Tangier Island.
[ 8. 7. ] Individuals younger than 21 years of age who are approved for DMAS psychiatric residential treatment center (RTC) Level C programs as defined in 12VAC30-130-860. Any individual admitted to an RTC Level C program for behavioral health services will be temporarily excluded from CCC Plus until after they are discharged. RTC Level C services may be transitioned to the CCC Plus program in the future.
[ 9. 8. ] Individuals with end stage renal disease (ESRD) and in fee-for-service at the time of enrollment will be automatically enrolled into CCC Plus but may request to be disenrolled and remain in fee-for-service. The department will exclude these individuals if requested by the member within the first 90 days of CCC Plus enrollment. However, a member who does not request an extension within the first 90 days of CCC Plus enrollment or who develops ESRD while enrolled in CCC Plus will remain in CCC Plus.
[ 10. 9. ] Individuals who are institutionalized in certain state and private intermediate care facility for individuals with intellectual disabilities (ICF/IID) and mental health facilities as specified in the CCC Plus contract. "Intermediate care facility for individuals with intellectual disabilities" or "ICF/IID" means a facility licensed by the Department of Behavioral Health and Developmental Services in which care is provided to intellectually disabled individuals who are not in need of skilled nursing care, but who need more intensive training and supervision than would be available in a rooming home, boarding home, or group home. Such facilities must comply with Title XIX standards, provide health or rehabilitative services, and provide active treatment to [ enrollees members ] toward the achievement of a more independent level of functioning.
[ 11. 10. ] Individuals who are patients at nursing facilities operated by the Veterans Administration.
[ 12. 11. ] Individuals participating in the CMS Independence at Home (IAH) demonstration. However, IAH individuals may enroll in CCC Plus if they choose to disenroll from IAH.
[ 13. 12. ] Certain individuals in out-of-state placements as specified in the CCC Plus contract.
[ 14. 13. ] Individuals placed on spenddown. However, spenddown individuals are included if they are residing in a nursing home.
[ 15. Individuals enrolled in the department's Money Follows the Person Demonstration project. "Money Follows the Person" means a demonstration project administered by DMAS that is designed to create a system of long-term services and supports that better enable enrollees to transition from certain long-term care institutions into the community. ]
[ 16. 14. ] Incarcerated individuals. Individuals on house arrest are not considered incarcerated.
[ 17. 15. ] All children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program, established pursuant to Chapter 50 of Title 38.2 (§ 38.2-5000 et seq.) of the Code of Virginia, who shall maintain enrollment in Medicaid fee-for-service.
[ 16. Individuals who have any insurance purchased through the Health Insurance Premium Payment (HIPP) program, as defined in 12VAC30-20-205 and 12VAC30-20-210.
17. Individuals who are included in the Medicaid expansion population, but are not identified as medically complex. These individuals are covered through the Medallion program.]
C. Enrollment in CCC Plus will be mandatory for eligible individuals. The department shall have sole authority and responsibility for the enrollment of individuals into the CCC Plus program and for excluding [ enrollees members ] from CCC Plus.
E. The MCO shall notify the [ enrollee member ] of enrollment in the MCO's plan through a letter submitted simultaneously with the handbook. Upon disenrollment from the plan, the MCO shall notify the [ enrollee member ] through a disenrollment notice that coverage in the MCO's plan will no longer be effective.
1. The [ enrollee member ] will be, at a minimum, notified of the [ enrollee's member's ] assigned MCO, right to select another CCC Plus MCO operating in the [ enrollee's member's ] locality, CCC Plus service begin date, and instructions for the individual or the individual's designee to contact DMAS or its enrollment broker to either:
3. For the initial 90 calendar days following the effective date of CCC Plus enrollment, the [ enrollee member ] will be permitted to disenroll from one MCO and enroll in another without cause. This 90-day timeframe applies only to the [ enrollee's member's ] initial start date of enrollment in CCC Plus; it does not reset or apply to any subsequent enrollment periods. After the initial 90-day period following the initial enrollment date, the [ enrollee member ] may not disenroll without cause until the next annual open enrollment period.
a. Open enrollment will occur at least once every 12 months per 42 CFR 438.56(c)(2) and 42 CFR 438.56(f)(1). The open enrollment will occur during October through December with any changes to take effect the following January 1. [ For individuals not participating in Medicaid expansion, open enrollment will occur from October 1st to December 18th for a January 1 effective date. Individuals participating through Medicaid expansion will have an open enrollment period from November 1  December 18th for a January 1 effective date. ]
b. Within 60 days prior to the open enrollment effective date, the department will inform [ enrollees members ] of the opportunity to remain with the current plan or change to another plan without cause. Those individuals who do not choose a new MCO during the open enrollment period shall remain in their current MCO until their next open enrollment effective date.
[ H. Individuals transferring from CCC and Medallion 3.0 (other than HAP as described in subdivision A 4 of this section) will transition with a CCC Plus service begin date of January 1, 2018. However, DMAS retains the authority to change this date if deemed necessary by DMAS or CMS. Individuals impacted by a delay will be notified of their new CCC Plus service begin date. ]
[ I. H. ] DMAS shall utilize an intelligent default assignment process to assign eligible individuals, other than the ABD populations described in subdivision A 5 of this section, to a CCC Plus MCO contracted to operate in their locality. If none of the criteria used in the intelligent default assignment process applies to an individual, the individual will be randomly assigned to a CCC Plus MCO operating in the individual's locality. The intelligent default assignment process will, at a minimum, take into account:
1. The individual's previous Medicare and Medicaid MCO enrollment within the past two months if known at the time of assignment [ , the expansion member's child's Medicaid MCO enrollment ] ; and
[ J. I. ] Consistent with 42 CFR 438.56(d), DMAS must permit an [ enrollee member ] to disenroll at any time for cause.
1. [ An enrollee A member ] may disenroll from the [ enrollee's member's ] current plan for the following reasons:
a. The [ enrollee member ] moves out of the MCO's service area;
b. The MCO does not, because of moral or religious objections, cover the service the [ enrollee member ] seeks;
c. The [ enrollee member ] needs related services (e.g., a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the provider network; and the [ enrollee's member's ] primary care provider or another provider determines that receiving the services separately would subject the individual to unnecessary risk;
d. The [ enrollee member ] would have to change residential, institutional, or employment supports provider based on that provider's change in status from an in-network to an out-of-network provider with the MCO and, as a result, the [ enrollee member ] would experience a disruption in residence or employment; and
e. Other reasons as determined by DMAS, including poor quality of care, lack of access to services covered under this MCO, or lack of access to providers experienced in dealing with the [ enrollee's member's ] care needs.
2. The [ enrollee's member's ] request to change from one plan to another outside of open enrollment, or for cause request, may be submitted orally or in writing to the department as provided for in 42 CFR 438.56(d)(1) and cite the reasons why the [ enrollee member ] wishes to disenroll from one plan and enroll in another. The department will review the request in accordance with cause for disenrollment criteria defined in 42 CFR 438.56(d)(2). The department will respond to "for cause" requests, in writing, within 15 business days of the department's receipt of the request. In accordance with 42 CFR 438.56(e)(2), if the department fails to make a determination by the first day of the second month following the month in which the [ enrollee member ] files the request, the disenrollment request shall be considered approved and effective on the date of approval. [ Enrollees Members ] who are dissatisfied with the department's determination of the [ enrollee's member's ] request to disenroll from one plan and enroll in another for cause shall have the right to appeal through the state fair hearing process in 12VAC30-110.
[ K. J. ] CCC Plus eligible individuals who have been previously enrolled with a CCC Plus MCO and who regain eligibility for the CCC Plus program within 60 calendar days of the effective date of exclusion or disenrollment will be reassigned to the same MCO whenever possible and without going through the selection or assignment process.
12VAC30-120-615. CCC Plus providers; Medicaid enrollment process.
[ A. All individuals and entities who provide services of any type to CCC Plus members, including health care providers, pharmacies, ordering, referring, and prescribing providers, and providers who do not participate in Medicaid fee-for-service shall abide by all CCC Plus contract requirements regarding Provider Enrollment, pursuant to the 21st Century Cures Act (Pub. L. No. 114-255).
B. Each provider shall be screened and enrolled with DMAS through the DMAS provider enrollment system by December 1, 2019. The MCO shall ensure that all providers are registered in the DMAS provider enrollment system prior to contracting with the provider. ]
8. In accordance with 42 CFR 447.50 through 42 CFR 447.60, the MCO shall not impose any cost sharing obligations on members except as set forth in 12VAC30-20-150 and 12VAC30-20-160 [ and as described in the CCC Plus contract ] .
D. The MCO's coverage rules for contract covered services shall also ensure compliance with federal EPSDT coverage requirements for [ enrollees members ] younger than 21 years of age.
[ F. The MCO shall not apply any financial requirement or treatment limitation to behavioral health benefits, including mental health or addiction, recovery and treatment benefits, in any classification (inpatient, out-patient, emergency and pharmacy) that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification furnished to members.
G. The MCO shall provide behavioral health benefits to the member in every classification in which medical/surgical benefits are provided.
H. The MCO shall not place limits on behavioral health benefits that is no more restrictive than limits in place under fee-for-service Medicaid.
I.The MCO may cover, in addition to services covered under the state plan, any services necessary for compliance with the requirements for parity in mental health and substance abuse benefits in 42 CFR § 438, subpart K.
J. If a member of the MCO is provided behavioral health benefits in any classification of benefits (inpatient, outpatient, emergency care, or prescription drugs), the behavioral health benefits must be provided to the member in every classification in which medical/surgical benefits are provided.
K. The MCO shall not impose an aggregate lifetime dollar limit on any behavioral health benefit regardless of classification.
L. The MCO may not impose non-quantitative treatment limits (NQTL) for behavioral health benefits in any classification (inpatient, out-patient, emergency care or prescription drugs) unless, under the policies and procedures of the MCO as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to behavioral health benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation for medical/surgical benefits in the classification.
M. The MCO shall provide documentation necessary to establish and demonstrate compliance with mental health parity requirements in 42 CFR 438, subpart K, regarding the provision of behavioral health benefits. ]
1. Within the first [ 90 30 ] calendar days of a member's enrollment, the MCO shall allow a member to maintain the member's current providers, including out-of-network providers. [ For members enrolling effective on or after April 1, 2018, the continuity of care time period will change to a minimum of 30 calendar days. ] The MCO shall extend this timeframe as necessary to ensure continuity of care pending the provider contracting with the MCO or the member's safe and effective transition to a contracted provider. DMAS has sole discretion to extend the continuity of care period timeframe.
B. The Appeals Division maintains an appeals and fair hearings system for [ enrollees members ] (referred to as "appellants" once the appeal process has begun) to challenge appeal decisions rendered by the MCO in response to [ enrollee member ] appeals of adverse benefit determinations related to Medicaid services. Exhaustion of the MCO's appeals process is a prerequisite to requesting a state fair hearing with the department. Appellants who meet the criteria for a state fair hearing shall be entitled to a [ state fair ] hearing before a department hearing officer.
C. The MCO shall conduct an internal appeal [ hearing ] , pursuant to 42 CFR Part 431 Subpart E and 42 CFR Part 438 Subpart F, and issue a written decision that includes its findings and information regarding the appellant's right to file an appeal with DMAS for a state fair hearing for Medicaid appeals.
D. [ Enrollees Members ] must be notified in writing of the MCO's internal appeals process in accordance with 42 CFR 438.400 et seq.:
E. [ Enrollees Members ] must be notified in writing of their right to an external appeal to DMAS upon receipt of the MCO's final internal appeal decision.
F. An appellant shall have the right to representation by an attorney or an authorized representative at the internal appeal and external appeal before DMAS. [ 1. ] An authorized representative may be designated to represent the appellant, pursuant to 12VAC30-110-60, 12VAC30-110-1380, and 12VAC30-110-1390, at the internal appeal and external appeal before DMAS. [ The appellant shall designate the authorized representative in a written statement that is signed by the appellant whose Medicaid benefits were adversely affected. If the appellant is physically unable to sign a written statement and proof is submitted to that effect, the department or MCO shall allow a family member or other person acting on the appellant's behalf to be the authorized representative. If the appellant is mentally unable lacks the mental capacity to sign a written statement, the department or MCO shall require written documentation that a family member or other person has been appointed or designated as the appellant's authorized representative.
4. An appellant may revoke representation by another person at any time. The revocation is effective when the department receives written notice from the appellant. ]
G. Any communication from [ an enrollee a member ] or the [ enrollee's member's ] authorized representative that expresses the [ enrollee's member's ] desire to present his case to a reviewing authority shall constitute an appeal request.
2. The appellant or the appellant's authorized representative may examine witnesses, documents, or both; provide testimony; submit evidence; and advance relevant arguments during the [ state fair ] hearing.
J. The appellant [ enrollee member ] has the right to have his benefits continued during the MCO's appeal or the state fair hearing.
d. The [ enrollee member ] requests that the benefits be continued.
2. For continuation of benefits for an internal appeal with the MCO, the [ enrollee member ] or authorized representative must file the appeal before the effective date of the adverse benefit determination or within 10 calendar days of the mail date of the MCO's notice of the adverse benefit determination.
3. For continuation of benefits for a state fair hearing, the [ enrollee member ] , or authorized representative must file the appeal within 10 calendar days of the mail date of the MCO's final appeal decision.
4. The MCO shall also continue benefits for [ enrollees members ] who initiate a state fair hearing directly because of deemed exhaustion of appeals processes due to failure of the MCO to adhere to the notice and timing requirements in 42 CFR 438.408.
5. If the final resolution of the appeal or state fair hearing is adverse to the [ enrollee member ] , that is, upholds the MCO's adverse benefit determination, the MCO may recover the costs of services furnished to the [ enrollee member ] while the appeal and the state fair hearing was pending, to the extent they were furnished solely because of the pending appeal.
K. The MCO and the department shall maintain an expedited process for appeals when an appellant's treating provider indicates in making the request on the [ enrollee's member's ] behalf or supporting the [ enrollee's member's ] request that taking the time for a standard resolution could seriously jeopardize the [ enrollee's member's ] life, physical or mental health, or ability to attain, maintain, or regain maximum function.
2. [ Enrollees Members ] must exhaust the MCO's internal appeals processes prior to filing an expedited appeal request with the department with the exception of those [ enrollees members ] [ with who gain ] direct access to state fair hearings because of deemed exhaustion of appeals processes with the MCO [ pursuant to 42 CFR 438.402(c)(1)(i)(A) ] .
3. The MCO and the department may extend the timeframes for resolution of an expedited appeal by up to 14 calendar days if the [ enrollee member ] or the [ enrollee's member's ] authorized representative requests the extension, or if the MCO or the department shows that there is a need for additional information and how the delay is in the [ enrollee's member's ] best interest.
4. Requirements following extension. If the MCO extends the timeframes not at the request of the [ enrollee member ] , it shall complete the following:
a. Promptly notify the [ enrollee member ] of the reason for an extension and provide the date the extension expires; and
b. Resolve the appeal as expeditiously as the [ enrollee's member's ] health condition requires and no later than the date the extension expires.
F. DMAS shall take final administrative action within 90 days from the date the [ enrollee member ] filed an MCO appeal, not including the number of days the [ enrollee member ] took to subsequently file for a state fair hearing.
1. The appellant or authorized representative requests to reschedule or continue the [ state fair ] hearing;
2. The appellant or authorized representative provides good cause for failing to keep a scheduled [ state fair ] hearing appointment, and the Appeals Division reschedules the [ state fair ] hearing;
4. Following a [ state fair ] hearing, the hearing officer orders an independent medical assessment as described in 12VAC30-120-670 H 1;
5. The hearing officer leaves the [ state fair ] hearing record open after the [ state fair ] hearing in order to receive additional evidence or argument from the appellant;
6. The hearing officer receives additional evidence from a person other than the appellant or the appellant's authorized representative, and the appellant requests to comment on such evidence in writing or to have the [ state fair ] hearing reconvened to respond to such evidence; or
1. If an appellant or authorized representative requests or causes a delay within 30 days of the request for a [ state fair ] hearing, the 90-day time limit will be extended by the number of days from the date when the first [ state fair ] hearing was scheduled until the date to which the [ state fair ] hearing is rescheduled.
2. If an appellant or authorized representative requests or causes a delay within 31 to 60 days of the request for a [ state fair ] hearing, the 90-day time limit will be extended by 1.5 times the number of days from the date when the first [ state fair ] hearing was scheduled until the date to which the [ state fair ] hearing is rescheduled.
3. If an appellant or authorized representative requests or causes a delay within 61 to 90 days of the request for a [ state fair ] hearing, the 90-day time limit will be extended by two times the number of days from the date when the first [ state fair ] hearing was scheduled until the date to which the [ state fair ] hearing is rescheduled.
I. Post [ state fair ] hearing delays requested or caused by an appellant or authorized representative (e.g., requests for the record to be left open) will result in a day-for-day delay for the decision date. The department shall provide the appellant and authorized representative with written notice of the reason for the decision delay and the delayed decision date, if applicable.
12VAC30-120-660. Pre [ state fair ] hearing decisions.
A. If the Appeals Division determines that any of the conditions as described in this subsection exist, a [ state fair ] hearing will not be held and the appeal process shall be terminated.
(1) The filer did not reply [ within 10 calendar days ] to the request for authorization to represent the appellant [ within 10 calendar days ] ; or
a. The MCO's internal appeals process was not exhausted prior to the [ enrollee's member's ] request for a state fair hearing;
a. The Appeals Division schedules a [ state fair ] hearing and sends a written schedule letter notifying the appellant or the appellant's authorized representative of the date, time, and location of the [ state fair ] hearing; the appellant or the appellant's authorized representative fails to appear at the scheduled [ state fair ] hearing; and the Appeals Division sends a letter to the appellant for an explanation as to why he failed to appear; and
(1) The appellant did not reply [ within 10 calendar days ] to the request for an explanation that met good cause criteria [ within 10 calendar days ] ; or
b. The Appeals Division sends a written schedule letter requesting that the appellant or the appellant's authorized representative provide a telephone number at which he can be reached for a telephonic [ state fair ] hearing, and the appellant or the appellant's authorized representative failed to respond within 10 calendar days to the request for a telephone number at which he could be reached for a telephonic [ state fair ] hearing.
B. Remand to the MCO. If the hearing officer determines from the record, without conducting a [ state fair ] hearing, that the case might be resolved in the appellant's favor if the MCO obtains and develops additional information, documentation, or verification, the hearing officer may remand the case to the MCO for action consistent with the hearing officer's written instructions pursuant to 12VAC30-110-210 D.
12VAC30-120-670. [ State fair ] [ Hearing hearing ] process and final decision.
A. All [ state fair ] hearings must be scheduled at a reasonable time, date, and place, and the appellant and the appellant's authorized representative shall be notified in writing prior to the hearing.
1. The [ state fair ] hearing location will be determined by the Appeals Division.
2. A [ state fair ] hearing shall be rescheduled at the appellant's request no more than twice unless compelling reasons exist.
3. Rescheduling the [ state fair ] hearing at the appellant's request will result in automatic waiver of the 90-day deadline for resolution of the appeal. The delay date for the decision will be calculated as set forth in 12VAC30-120-650 [ H and ] I.
B. The [ state fair ] hearing shall be conducted by a department hearing officer. The hearing officer shall review the complete record for all MCO decisions that are properly appealed; conduct informal, fact-gathering [ state fair ] hearings; evaluate evidence presented; research the issues; and render a written final decision.
C. Subject to the requirements of all applicable federal and state laws regarding privacy, confidentiality, disclosure, and personally identifiable information, the appeal record shall be made accessible to the appellant and authorized representative at a convenient place and time before the date of the [ state fair ] hearing, as well as during the [ state fair ] hearing. The appellant and the appellant's authorized representative may examine the content of the appellant's case file and all documents and records the department will rely on at the [ state fair ] hearing except those records excluded by law.
D. Appellants who require the attendance of witnesses or the production of records, memoranda, papers, and other documents at the [ state fair ] hearing may request in writing the issuance of a subpoena. The request must be received by the department at least 10 working days before the scheduled [ state fair ] hearing. Such request shall (i) include the witness's or respondent's name, home and work addresses, and county or city of work and residence; and (ii) identify the sheriff's office that will serve the subpoena.
E. The hearing officer shall conduct the [ state fair ] hearing; decide on questions of evidence, procedure, and law; question witnesses; and assure that the [ state fair ] hearing remains relevant to the issue being appealed. The hearing officer shall control the conduct of the [ state fair ] hearing and decide who may participate in or observe the [ state fair ] hearing.
F. [ State fair ] [ Hearings hearings ] shall be conducted in an informal, nonadversarial manner. The appellant or the appellant's authorized representative shall have the right to bring witnesses, establish all pertinent facts and circumstances, present an argument without undue interference, and question or refute the testimony or evidence, including the opportunity to confront and cross-examine agency representatives.
H. The hearing officer may leave the [ state fair ] hearing record open for a specified period of time after the [ state fair ] hearing in order to receive additional evidence or argument from the appellant or the appellant's authorized representative.
3. If the hearing officer receives additional evidence from an entity other than the appellant or the appellant's authorized representative, the hearing officer shall send a copy of such evidence to the appellant and the appellant's authorized representative and give the appellant or the appellant's authorized representative the opportunity to comment on such evidence in writing or to have the [ state fair ] hearing reconvened to respond to such evidence.
4. Any additional evidence received will become a part of the [ state fair ] hearing record, but the hearing officer must determine whether or not it will be used in making the decision.
I. After conducting the [ state fair ] hearing, reviewing the record, and deciding questions of law, the hearing officer shall issue a written final decision that sustains or reverses, in whole or in part, the MCO's adverse benefit determination or remands the case to the MCO for further evaluation consistent with the hearing officer's written instructions. Some decisions may be a combination of these dispositions. The hearing officer's final decision shall be considered as the department's final administrative action pursuant to 42 CFR 431.244(f). The final decision shall include:
J. A copy of the [ state fair ] hearing record shall be forwarded to the appellant and the appellant's authorized representative with the final decision.
D. When copies are requested from records in the Appeals Division's custody, the required fee shall be waived if the copies are requested in connection with [ an enrollee's a member's ] own appeal.
A. The Appeals Division maintains an appeal process for network and Medicaid-enrolled providers of Medicaid services that have rendered services to [ enrollees members ] and are requesting to challenge an MCO's reconsideration decision regarding an adverse action affecting service authorization or payment. The MCO's internal reconsideration process is a prerequisite to filing for an external appeal to the department's provider appeal process. The appeal process is available to network and Medicaid-enrolled providers that (i) have rendered services and have been denied payment in whole or part for Medicaid covered services; (ii) have rendered services and have been denied authorization for the services; and (iii) have received a notice of program reimbursement or overpayment demand from the department or its contractors. Providers that have had their enrollment in the MCO's network denied or terminated by the MCO do not have the right to an external appeal with the Appeals Division.