Arkansas Code of 1987 (2023) › Title 20 - PUBLIC HEALTH AND WELFARE (§§ 20-2-101 — 20-86-113) › Subtitle 5 - SOCIAL SERVICES (§§ 20-76-101 — 20-86-113) › Chapter 77 - MEDICAL ASSISTANCE (§§ 20-77-101 — 20-77-2811) › Subchapter 17 - MEDICAID FAIRNESS ACT (§§ 20-77-1701 — 20-77-1718) › Section 20-77-1704 - Provider administrative appeals allowed

(a)
The General Assembly finds it necessary to:
(1)
Clarify its intent that providers have the right to fair and impartial administrative appeals; and
(2)
Emphasize that this right of appeal is to be liberally construed and not limited through technical or procedural arguments by the Department of Human Services.
(b)
(1)
(A)
In response to an adverse decision, a provider may appeal on behalf of the recipient or on its own behalf, or both, regardless of whether the provider is an individual or a corporation.
(B)
(i)
A provider appeal shall be governed by the Arkansas Administrative Procedure Act, §
25-15-201
et seq., except as otherwise provided in this subchapter.
(ii)
Multiple appeals by the same provider may be consolidated.
(C)
An administrative law judge employed by the Department of Health shall conduct all Medicaid provider administrative appeals of adverse decisions under this subchapter.
(2)
The provider may appear:
(A)
In person or through a corporate representative; or
(B)
With prior notice to the Department of Health, through legal counsel.
(3)
(A)
A Medicaid recipient may attend any hearing related to his or her care, but the Department of Health may not make his or her participation a requirement for provider appeals.
(B)
The Department of Health may compel the recipient's presence via subpoena, but failure of the recipient to appear shall not preclude the provider appeal.
(c)
(1)
An administrative law judge shall be guided by the need to reach a just determination and may depart from strict adherence to the formal rules of evidence.
(2)
An administrative law judge shall exclude irrelevant, immaterial, and unduly repetitious evidence.
(3)
An administrative law judge shall receive oral or documentary evidence not privileged if the oral or documentary evidence is of a type commonly relied upon by a reasonably prudent person in the conduct of his or her affairs.
(4)
An administrative law judge shall rule on each evidentiary objection, and the objection and ruling shall be noted of record.
(d)
(1)
(A)
If a provider submits evidence that the Department of Human Services has not had an opportunity to consider before the hearing, an administrative law judge shall continue the hearing for thirty (30) days to allow the Department of Human Services to review the evidence.
(B)
An administrative law judge may extend the thirty-day continuance under subdivision (d)(1)(A) of this section for good cause.
(2)
Before the end of a continuation under subdivision (d)(1) of this section, the Department of Human Services shall send the provider and the administrative law judge notice stating whether the Department of Human Services will modify its decision with an explanation of the modification.
(3)
(A)
Unless the provider notifies the administrative law judge and the Department of Human Services that the provider wishes to withdraw its appeal, the administrative law judge shall notify the parties of the date and time at which the hearing will continue.
(B)
The date under subdivision (d)(3)(A) of this section shall be no later than thirty (30) days after the Department of Human Services' notification under subdivision (d)(2) of this section.
(e)
A provider does not have standing to appeal a decision denying payment or ordering recoupment of payments already made if the provider has not furnished any service for which payment has been denied.
(f)
(1)
Providers, like Medicaid recipients, have standing to appeal to circuit court unfavorable administrative decisions under the Arkansas Administrative Procedure Act, §
25-15-201
et seq.
(2)
The Department of Human Services may seek judicial review of a final, appealable order issued by an administrative law judge.
(g)
Burdens of proof shall be determined under the Arkansas Administrative Procedure Act, §
25-15-201
et seq.
(h)
(1)
(A)
A final decision by an administrative law judge in favor of a provider is a final appealable order.
(B)
A final decision under this section shall not be overturned by the Director of the Division of Medical Services of the Department of Human Services or another official within the Department of Human Services.
(2)
(A)
Within thirty (30) days after August 16, 2013, the Department of Human Services shall request a waiver from the Centers for Medicare & Medicaid Services of the single state agency requirement contained in
42 C.F.R. § 431.10
to allow final decisions in Medicaid provider administrative appeals to be issued by an administrative law judge in a separate agency.
(B)
An administrative law judge shall follow the rules adopted by the Department of Human Services in making final decisions.
(3)
The Department of Human Services shall make available to the public all communications with regard to the waiver application under subdivision (h)(2)(A) of this section and shall work jointly with provider representatives to obtain and maintain approval for the waiver.
(i)
(1)
Until the waiver under subdivision (h)(2) of this section is approved, an administrative law judge's decision shall constitute a recommended decision to the Director of the Division of Medical Services.
(2)
(A)
The Director of the Division of Medical Services, upon a review of the record submitted by an administrative law judge, shall adopt, reject, or modify the recommended decision.
(B)
A modification or rejection of an administrative law judge's decision shall state with particularity the reasons for the modification or rejection, shall include references to the record, and shall constitute the final decision.
(C)
As an alternative to the process under subdivision (i)(2)(B) of this section, the Director of the Division of Medical Services may remand the decision to the administrative law judge with additional guidance on Medicaid policy.
(3)
(A)
The Director of the Division of Medical Services shall issue a final decision under this subsection within thirty (30) days after receipt of the administrative law judge's decision.
(B)
Unless the Director of the Division of Medical Services modifies or rejects the recommended decision of the administrative law judge within thirty (30) days after receipt of the administrative law judge's decision, the recommended decision is the final decision.
(j)
If an administrative appeal is filed by both provider and recipient concerning the same subject matter, then the department may consolidate the appeals.
(k)
(1)
This subchapter shall apply to all pending and subsequent appeals that have not been finally resolved at the administrative or judicial level as of April 5, 2005.
(2)
The amendatory provisions of this act apply to a pending and subsequent appeal that has not been finally resolved at the administrative or judicial level on August 16, 2013.
Amended by Act 2013, No. 562,§ 4, eff. 8/16/2013.
Acts 2005, No. 1758, § 1.