California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51552 - AA Formal Appeals Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider may appeal the Department's
					 decision on the AAR for a final PIRL settlement only. There shall be no appeal
					 on an AAR for a tentative PIRL settlement. The appeal shall be filed and
					 conducted in accordance with the applicable procedural requirements of Article
					 1.5, except as modified by this section, including the following:
(1) The appeal shall be submitted within 30
					 days after notification of the Department's decision on the AAR.
(2) The provider shall present its issues and
					 evidence first at the hearing, as they shall have the burden of going
					 forward.
(3) The provider has the
					 burden of proof of demonstrating by a preponderance of the evidence, that the
					 provider's position regarding disputed issues is correct.
(4) In order to demonstrate that it is
					 entitled to relief from the PIRL and that the AA decision should be overturned,
					 the provider has the burden of demonstrating by a preponderance of the evidence
					 that the Department's AA decision is inconsistent with the applicable
					 regulatory provisions and that the provider's alternative is consistent with
					 the applicable regulatory provisions.
(5) If the Department's AA decision is
					 proved, by a preponderance of evidence, inconsistent with the applicable
					 regulatory provisions, and the provider has not proved by a preponderance of
					 the evidence that its position is consistent with the applicable regulatory
					 provisions, then the Administrative Law Judge (ALJ) may fashion whatever relief
					 is necessary to obtain consistency with the applicable regulatory
					 provisions.
(6) Items that are not
					 subject to an AA, as specified in Section
					 51551, shall not be subject to
					 appeal.
(7) The provider shall be
					 paid at the PIRL initially determined by the Department pending determination
					 of a formal appeal.
(8) Any
					 underpayments, identified in the appeal decision, shall be repaid to the
					 provider, together with interest computed at the legal rate of interest
					 beginning the later of the date the payment is received by the Department or
					 the date the appeal is formally accepted by the Department.
(9) The evidence to be submitted by the
					 provider at a formal appeal hearing that was not provided to the Department nor
					 specifically and individually identified as available to the Department, during
					 the AA process excluding oral testimony, must be submitted to the Department 30
					 days before the scheduled date of the hearing. The only exception, is when a
					 hearing is scheduled within 45 days from the date notice is given. In this
					 latter case, evidence must be submitted 15 days before the scheduled date of
					 the hearing. Failure to submit this information within the specified time
					 frames shall result in its exclusion from the formal appeal hearing and
					 record.
(10) Recalculation of the
					 PIRL due to an appeal decision shall not give rise to any further appeal
					 rights.
(11) If results of an audit
					 appeal of the cost report or any prior fiscal period PIRL, AA or appeal, change
					 data used in the settlement fiscal period PIRL, the PIRL shall be recalculated.
					 The recalculation shall not give rise to further appeal rights.
(12) If an issue in an AAR is not accepted
					 pursuant to Section
					 51550(e)(2) and
					 (e)(3), the ALJ may only consider the
					 evidence that was presented in the AAR and not any additional information or
					 testimony. If the ALJ determines that the issue should have been accepted, the
					 issue shall be remanded for a response to the merits.
(13) Only those issues that were clearly
					 identified in a timely filed AAR, including an estimated dollar amount for each
					 issue may be accepted as issues on a formal appeal.