reglab/statecodes huggingface dataset:
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 1.5 - Provider Audit Appeals › Section 51018 - Home Office -Chain Organization Related Entities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The home office of a chain organization has no separate
						right to an individual hearing under this article. Where a provider in a chain
						organization disputes an audit or examination finding concerning the allocation
						of home office costs, other related entity costs or any other matter affecting
						all or some of the providers in the chain organization, all providers in the
						chain organization that are affected by the issue in dispute shall be made
						parties to the proceedings for the purpose of resolution of that issue only, in
						accordance with Section
						51030.
Note: Authority cited: Sections
						  14105,
						  14124.5,
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51019 - Amended Cost Reports

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
					 amended cost report may be submitted by a provider and accepted by the
					 Department for the fiscal period or periods for which proceedings are pending
					 under this article.
(b) The hearing
					 officer may suspend the proceedings until identification of any additional
					 disputes that may result from an amended report filed by a provider.
(c) Additional issues which are raised by
					 accepted cost report amendments may be included in the proceedings at the
					 request of the provider in accordance with Section
					 51022.
(d) The hearing officer may dismiss the
					 proceeding without prejudice to the right to request a subsequent hearing under
					 this article when the hearing officer deems this course to be
					 appropriate.
Note: Authority cited: Sections
						  14105,
						  14124.5,
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51020 - Amended Audit Report

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
					 amended audit report may be issued by or on behalf of the Department for the
					 fiscal period or periods for which proceedings are pending under this
					 article.
(b) The hearing officer
					 may suspend the proceedings until identification of any additional disputes
					 that may result from an amended audit report.
(c) Additional issues in dispute which are
					 raised by the amended audit report may be included in the proceedings at the
					 request of the provider in accordance with Section
					 51022.
(d) The hearing officer may dismiss the
					 proceeding without prejudice to the right to request a subsequent hearing under
					 this article when the hearing officer deems this course to be
					 appropriate.
Note: Authority cited: Sections
						  14105,
						  14124.5,
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51021 - Exit Conference and Audit Report

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The provider shall be afforded a
					 reasonable opportunity to participate in an exit conference after the
					 conclusion of any field audit or examination of records or reports of a
					 provider, by or on behalf of the Department, and prior to the issuance of the
					 Audit Report. The purpose of the exit conference is to:
(1) Inform the provider of the audit or
					 examination findings and the supporting reasons and evidence.
(2) Inform the provider of the specific
					 instances in which no records were found to substantiate claims billed to the
					 program which was the subject of the audit or examination.
(3) Allow the provider an opportunity to
					 present relevant information concerning the audit or examination
					 findings.
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 1.5 - Provider Audit Appeals › Section 51022 - Request for Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
					 Institutional provider may request a hearing for any disputed audit or
					 examination finding as follows:
(1) A written
					 request shall be filed with the Department within 60 calendar days of the
					 receipt of the written notice of the audit or examination findings.
(2) This request may be amended at any time
					 during the 60 calendar day period.
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 1.5 - Provider Audit Appeals › Section 51023 - Informal Level of Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 If the hearing officer determines that an informal level of review is
					 appropriate, it shall be ordered and scheduled as soon as reasonably possible.
					 The hearing officer, or a hearing auditor designated by the hearing officer,
					 shall preside at this informal level of review.
(b) Written notice of the time and place of
					 informal level of review shall be mailed to each party at least 30 calendar
					 days before the date of the informal level of review. This period may be
					 shortened with the consent of the parties. Any party may waive notice. This
					 notice may be combined with the notice of formal hearing.
(c) Efforts shall be made to resolve the
					 facts and issues in dispute in a fair and equitable manner, subject to the
					 requirements of state and federal law. Matters in dispute, raised in the
					 provider's Statement of Disputed Issues pursuant to Section
					 51022, which are not discussed or
					 raised at the informal level of review shall not be deemed waived.
(d) The proceedings at the informal level of
					 review shall be electronically recorded unless the parties agree
					 otherwise.
(e) The results of the
					 informal level of review shall be:
(1) Served
					 on the parties, within a reasonable time, in the form of a written Report of
					 Findings or Pretrial Order.
(2) For
					 Institutional providers, the report of findings shall be considered as final
					 unless the provider submits written request for a formal hearing in accordance
					 with Section
					 51024.
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 1.5 - Provider Audit Appeals › Section 51024 - Request for Formal Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The form and content of the request shall
					 be as specified in Section
					 51022(d).
(b) An Institutional provider shall have 30
					 calendar days following the receipt of the written Report of Findings within
					 which to file a request for formal hearing with the Director. The request shall
					 be deemed filed on the date mailed to the Department. The audit findings, as
					 amended by the Report of Findings, shall be considered final and deemed
					 dispositive of all issues raised i the Statement of Disputed Issues filed
					 pursuant to Section
					 51022 at the end of this period
					 unless good cause for late filing is found.
(c) A request for formal hearing filed after
					 the time permitted in subsection (b) shall be rejected unless the provider
					 establishes in writing good cause for late filing within 15 calendar days of
					 being notified of the untimeliness of its request.
(d) A formal hearing shall routinely be
					 scheduled in each case involving a Non-institutional provider. No separate
					 request for formal hearing shall be required.
1.
						Amendment filed 10-11-84; effective upon filing pursuant to Government Code
						Section
						11346.2(d)
						(Register 84, No. 41).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51025 - Notice of Formal Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Written notice of the time and place of formal hearing
						shall be mailed to each party at least 30 calendar days before the date of
						hearing. This period may be shortened with the consent of the parties. Any
						party may waive notice.
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51026 - Department Mailings. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51027 - Time and Place of Informal Level of Review and Formal Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing officer shall determine the
					 time and place of an informal level of review or formal hearing. The informal
					 level of review or formal hearing shall be held at one of the following
					 locations.
(1) In the County of:
(A) San Francisco if the provider resides
					 within the First Appellate District.
(B) Los Angeles if the provider resides
					 within the Second or Fourth Appellate District.
(C) Sacramento if the provider resides within
					 the Third or Fifth Appellate District.
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 1.5 - Provider Audit Appeals › Section 51028 - Merger of Successive Requests for Hearings. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						2).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51029 - Consolidation of Proceedings. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51030 - Hearing Officer's Authority

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing officer may, on his/her own
					 motion or the motion of any party, as the hearing officer deems appropriate:
(1) Consolidate for hearing or decision any
					 number of issues or appeals when the facts and circumstances are similar and no
					 substantial right of any party will be prejudiced.
(2) Join other parties, grant continuances
					 and hold additional formal hearings as necessary to dispose of all
					 issues.
(3) Hear any issue before
					 any other issue in the proceeding where it is found that the decision on that
					 issue could abate further proceedings.
(4) Prepare a proposed decision on any
					 separately heard issue for the Director's signature and postpone hearing on any
					 remaining issues until a final decision has been issued by the
					 Director.
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 1.5 - Provider Audit Appeals › Section 51031 - Severance of Issues. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51033 - Subpoenas and Witnesses

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The hearing officer shall issue subpoenas and subpoenas duces tecum before the
					 formal hearing, for attendance or production of documents at the formal
					 hearing, as necessary or at the request of any party. The hearing officer may
					 also issue subpoenas and subpoenas duces tecum after the formal hearing has
					 commenced. Compliance with the provisions of Section
					 1985,
					 California Code of Civil Procedure, shall be a condition precedent to the
					 issuance of a subpoena duces tecum.
(b) The process issued pursuant to subsection
					 (a) shall be extended to all parts of the State and shall be served in
					 accordance with the provisions of Sections
					 1987
					 and
					 1988,
					 California Code of Civil Procedure. No witness shall be obliged to attend at a
					 place out of the county in which he resides unless the distance be less than
					 150 miles from his place of residence except that the hearing officer, upon
					 affidavit of any party showing that the testimony of such witness is material
					 and necessary, may endorse on the subpoena an order requiring the attendance of
					 such witness.
(c) All witnesses
					 appearing pursuant to subpoena, other than the parties or officers or employees
					 of the State or any political subdivision thereof, shall receive fees and all
					 witnesses appearing pursuant to subpoena, except the parties, shall receive
					 mileage in the same amount and under the same circumstances as prescribed by
					 law for witnesses in civil actions in a superior court.
(d) Witnesses appearing pursuant to subpoena,
					 except the parties, who attend formal hearings at points so far removed from
					 their residences as to prohibit return thereto from day to day shall be
					 entitled, in addition to fees and mileage, to a per diem compensation of $3.00
					 for expenses of subsistence for each day of actual attendance and for each day
					 necessarily occupied in traveling to and from the hearing. Fees, mileage and
					 expenses of subsistence shall be paid by the party at whose request the witness
					 is subpoenaed.
Note: Authority cited: Sections
						  14105,
						  14124.5,
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51034 - Depositions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) On verified
					 petition of any party, the hearing officer may order that the testimony of any
					 material witness residing within or without the State be taken by deposition in
					 the manner prescribed by law for depositions in civil actions. The petition
					 shall set forth:
(1) The nature of the
					 pending proceeding.
(2) The name
					 and address of the witness whose testimony is desired.
(3) A showing of the materiality of his
					 testimony.
(4) A showing that the
					 witness will be unable or cannot be compelled to attend.
(5) A request for an order requiring the
					 witness to appear and testify before an officer named in the petition for that
					 purpose.
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 1.5 - Provider Audit Appeals › Section 51035 - Affidavits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any party may
					 mail or deliver to the opposing party, at least ten calendar days prior to a
					 formal hearing or a continued hearing, a copy of any affidavit to be introduced
					 in evidence, together with a notice as provided in subsection (b). Unless the
					 opposing party, within seven days after such mailing or delivery, mails or
					 delivers to the proponent a request to cross-examine an affiant, the right to
					 cross-examine such affiant is waived and the affidavit, if introduced in
					 evidence, shall be given the same effect as if the affiant had testified
					 orally. If an opportunity to cross-examine an affiant is not offered after
					 request therefor is made as herein provided, the affidavit may be introduced in
					 evidence, but shall be given only the same effect as other hearsay
					 evidence.
(b) The notice referred
					 to in subsection (a) shall be substantially in the following form:
NOTICE
The accompanying affidavit of (here insert name of
						affiant) will be introduced as evidence at the formal hearing in (here insert
						title of proceeding). (Here insert name of affiant) will not be called to
						testify orally and you will not be entitled to question him unless you notify
						(here insert name of proponent or his attorney) at (here insert address) that
						you wish to cross-examine him. To be effective your request must be mailed or
						delivered to (here insert name of proponent or his attorney) on or before (here
						insert a date seven days after the day of mailing or delivering the affidavit
						to the opposing party).
Note: Authority cited: Sections
						  14105,
						  14124.5,
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51036 - Preparation for Formal Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A party appearing at a formal hearing shall have
						necessary evidence and witnesses present and be ready to proceed. Each party
						shall make available sufficient copies, as indicated by the hearing officer, of
						any documents to be introduced in evidence. The hearing officer, if necessary
						and following reasonable notice, may require any or all parties to submit a
						written statement of contentions and reasons, together with any requested
						documents. Each party submitting written statements and documents shall also
						provide a copy to all other parties.
1.
						Amendment filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
2. Editorial correction of Authority cite (Register 95, No.
						45).
Note: Authority cited: Sections
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51037 - Conduct of Formal Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Testimony shall be taken only on oath,
					 affirmation or penalty of perjury.
(b) The proceedings at the formal hearing
					 shall be electronically recorded.
(c) Each party shall have the right to:
(1) Call and examine parties and
					 witnesses.
(2) Introduce
					 exhibits.
(3) Question opposing
					 witnesses and parties on any matter relevant to the issue even though the
					 matter was not covered in the direct examination.
(4) Impeach any witness regardless of which
					 party first called the witness to testify.
(5) Rebut the evidence against
					 him.
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 1.5 - Provider Audit Appeals › Section 51038 - Official Notice

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 hearing officer shall take official notice of those matters which must be
					 judicially noticed by a court under Section
					 451 of the
					 Evidence Code. The hearing officer may take official notice of those matters
					 set forth in Section
					 452 of the
					 Evidence Code.
(b) Parties present
					 at the formal hearing shall be informed of the matters to be noticed, and those
					 matters shall be noted in the record, referred to therein, or appended
					 thereto.
(c) Each party shall be
					 given a reasonable opportunity on request to refute the officially noticed
					 matters by evidence or by written or oral presentation of authority, the manner
					 of such refutation to be determined by the hearing officer.
Note: Authority cited: Sections
						  14105,
						  14124.5,
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51039 - Continued or Further Hearings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A hearing officer may continue a formal
					 hearing to another time or place if deemed advisable or upon request and a
					 showing of good cause.
(1) Written notice of
					 the time and place of the continued formal hearing, except as provided herein,
					 shall be in accordance with this article.
(2) Oral notice of the time and place of the
					 continued formal hearing may be given to each party present at the formal
					 hearing. Such oral notice shall be confirmed in writing by the hearing officer
					 subsequent to the formal hearing.
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 1.5 - Provider Audit Appeals › Section 51040 - Evidence

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In
					 Non-institutional provider cases, notwithstanding any other provision of these
					 regulations, and unless otherwise ordered by the assigned Administrative Law
					 Judge, the parties shall:
(1) Not less than
					 ten (10) calendar days prior to the pretrial conference, file a list of all
					 documents and other items to be offered into evidence at the formal hearing,
					 except for impeachment or rebuttal, with a brief statement following each
					 document describing its substance or purpose and the identity of the sponsoring
					 witness.
(2) Not less than seven
					 (7) calendar days prior to the date on which the formal hearing is scheduled to
					 commence, exchange copies of all documents and other items to be offered into
					 evidence at the formal hearing other than for impeachment or rebuttal. Each
					 proposed exhibit shall be premarked for identification.
(3) Prior to the commencement of the formal
					 hearing, any party proposing to object to the receipt in evidence of any
					 proposed exhibit shall advise the opposing party of such objection. The parties
					 shall confer with respect to any objections in advance of the formal hearing
					 and attempt to resolve them. Failure to comply with the requirements of (1) or
					 (2) above shall constitute a ground for objection to the introduction of
					 undisclosed documents and other items, into evidence other than for impeachment
					 or rebuttal.
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 1.5 - Provider Audit Appeals › Section 51041 - Representation at a Formal Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A hearing officer or hearing auditor may
					 refuse to allow any person to represent a party in any hearing when the person:
(1) Engages in unethical, disruptive or
					 contemptuous conduct.
(2)
					 Intentionally fails to comply with the proper instructions or orders of the
					 hearing officer or hearing auditor or the provisions of this
					 article.
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 1.5 - Provider Audit Appeals › Section 51042 - Oral Argument and Briefs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The hearing officer shall grant oral and may grant written argument at the
					 request of any party made prior to the close of the formal hearing. The parties
					 shall be advised as to the time and manner within which written argument is to
					 be filed.
(b) The hearing officer
					 may require any party to submit written memoranda pertaining to any or all
					 issues raised in the formal hearing.
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51043 - Disqualification of Hearing Officer

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A hearing officer shall voluntarily
					 withdraw from any proceedings in which the hearing officer:
(1) Cannot give a fair or impartial
					 hearing.
(2) Has an
					 interest.
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 1.5 - Provider Audit Appeals › Section 51044 - Decision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing
					 officer shall take the matter under submission at the conclusion of the
					 hearing. A proposed decision, in a form that may be adopted as the decision of
					 the Director, shall be submitted to the Director as soon as practical. A copy
					 of the proposed decision, upon submission to the Director, shall be:
(1) Filed by the Department as a public
					 record.
(2) Served by the
					 Department on each party in the case and each party's
					 representative.
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 1.5 - Provider Audit Appeals › Section 51045 - Reconsideration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department
					 may order a reconsideration of all or part of the case on its own motion or on
					 petition of any party. The power to order a reconsideration shall expire 30
					 calendar days after delivery or mailing of a decision to the provider. The
					 Department may grant a stay of expiration of its power to order
					 reconsideration:
(1) for up to 30 days for
					 the purpose of enabling a party to file a petition for reconsideration;
					 or
(2) for up to 10 days when
					 needed solely for the purpose of considering a petition filed prior to
					 expiration of its power to order reconsideration.
The petition of a party shall be deemed denied if the
						Department takes no action within the time allowed for ordering
						reconsideration.
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 1.5 - Provider Audit Appeals › Section 51046 - Judicial Review. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-15-85; effective thirtieth day thereafter (Register 85, No.
						29).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14171,
						  Welfare and Institutions Code. Reference: Section
						  14171,
						  Welfare and Institutions Code.
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 1.5 - Provider Audit Appeals › Section 51047 - Recovery of Overpayments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 When it is established upon audit that an overpayment has been made to a
					 provider, the Department shall begin liquidation of any overpayment to a
					 provider 60 days after issuance of the first Statement of Accountability or
					 demand for repayment. The demand for repayment or Statement of Accountability
					 shall be issued no later than 60 days after the issuance of the audit or
					 examination report establishing such overpayment. The overpayment shall be
					 recovered by any of the following methods:
(1) Lump sum payment by the
					 provider.
(2) Offset against
					 current payments due to the provider.
(3) A repayment agreement executed between
					 the provider and the Department.
(4) Any other method of recovery available to
					 and deemed appropriate by the Director.
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 1.5 - Provider Audit Appeals › Section 51048 - Administrative Review of Performance Under Selective Provider Contracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) As an
					 alternative to judicial review pursuant to Welfare and Institutions Code
					 Section
					 14087.27(a),
					 administrative review of disputes between a contracting hospital and the state
					 relating to performance under the Selective Provider Contracting Program shall
					 be heard by an independent hearing examiner appointed by the Director of the
					 Department of Health Services.
(b)
					 The independent hearing examiner shall conduct an administrative hearing and
					 render a proposed decision to be adopted by the Director pursuant to the
					 applicable procedural requirements of Article 1.5, Provider Audit Appeals
					 (Sections 51016-51047) with the following
					 exceptions:
(1) There shall be no exit
					 conference or informal hearings.
(2) All references to a hearing officer shall
					 apply to the independent hearing examiner appointed by the Director pursuant to
					 Welfare and Institutions Code Section
					 14087.27.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.1 - Limitations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A skilled
					 nursing and/or intermediate care facility Medi-Cal provider may, in accordance
					 with the regulations contained in Sections
					 51048.2 through
					 51048.8, appeal the decision of
					 the Department that a facility is not qualified to participate in the Medi-Cal
					 program.
(b) The Department in
					 rendering its determination shall set forth the pertinent facts and conclusions
					 upon which the determination is made, and shall notify the provider of its
					 right to appeal under subdivision (a).
(c) The effective date of a determination
					 rendered under this article is as follows:
(1)
					 A determination not to renew a certification is effective on the date the
					 existing certification actually expires.
(2) A determination to deny a certification
					 is effective upon the receipt of the determination by the provider, except, if
					 the provider files a request for reconsideration under Section
					 51048.3, the determination shall
					 be effective upon receipt of the reconsidered determination by the
					 provider.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.2 - Right to a Reconsideration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A skilled nursing and/or intermediate
					 care facility provider who disagrees with a determination that the skilled
					 nursing or intermediate care facility does not qualify as a provider of
					 services in the Medi-Cal program may, in accordance with Section
					 51048.3, request that the
					 Department reconsider that decision.
(b) The reconsideration of a nonrenewal of an
					 existing provider agreement shall be completed prior to the end of the
					 certification period.
(c) The
					 reconsideration of a denial of an initial application for certification shall
					 be made within 30 days of the receipt of the request for a
					 reconsideration.
1.
						Editorial correction of subsection (a) (Register 95, No.
						45).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14100.1,
						  Welfare and Institutions Code.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.3 - Request for Reconsideration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If a provider or authorized
					 representative of the provider requests a reconsideration, the request shall be
					 filed within 15 days after the date of receipt of notice of the determination
					 that the provider does not qualify as a Medi-Cal provider. The request shall be
					 filed with the Director of the Department of Health Services or the designee
					 authorized to accept such requests.
(b) A request for reconsideration shall:
(1) Be in writing.
(2) State the reasons upon which the provider
					 disagrees with the determination.
(3) Include relevant
					 evidence.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.4 - Reconsidered Determination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall review each request
					 for reconsideration that is filed in accordance with Section
					 51048.2. The Department shall
					 reconsider the determination and the reasons on which it was based. The
					 Department shall issue, within 30 days of the receipt of the request, a
					 reconsidered determination affirming, revising, in whole or in part, or
					 reversing the determination.
(b)
					 The reconsidered determination shall be based upon the evidence considered in
					 making the original determination and any other evidence submitted by the
					 provider and verified by the Department.
(c) The written reconsidered determination
					 shall be mailed to the provider or his authorized representative. The
					 reconsidered determination shall:
(1) Contain
					 the reason or reasons for affirming, revising or reversing the
					 determination.
(2) Inform the
					 provider of the right to a full evidentiary hearing.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.5 - Right to Full Evidentiary Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A skilled nursing facility or
					 intermediate care facility provider which disagrees with the Department's
					 reconsidered determination that the skilled nursing facility or intermediate
					 care facility does not qualify as a provider of services in the Medi-Cal
					 program may, by complying with Section
					 51048.6 request a full evidentiary
					 hearing or the provider may by-pass the informal reconsideration process and
					 appeal the Department's decision directly to the evidentiary hearing
					 process.
(b) The hearing shall
					 provide an opportunity for the provider to:
(1) Appear before an impartial hearing
					 officer to offer evidence to rebut the Department's determination concerning
					 the provider's ability to render services in the Medi-Cal program.
(2) Be represented by counsel or another
					 representative.
(3) Be heard in
					 person.
(4) Call
					 witnesses.
(5) Present oral and
					 documentary evidence.
(6)
					 Cross-examine witnesses.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.6 - Request for a Full Evidentiary Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A request for a full evidentiary hearing
					 shall be made in writing and signed by the provider or authorized
					 representative of the skilled nursing facility or intermediate care facility
					 concerned. The request shall be filed:
(1)
					 With the Director, Department of Health Services, or the designee authorized to
					 accept such requests.
(2) Within 15
					 days after the date the notice of the determination or reconsidered
					 determination is received by the provider.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.7 - Full Evidentiary Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department, within 30 days following
					 receipt of a request for a full evidentiary hearing submitted in accordance
					 with Section
					 51048.6, shall:
(1) Mail notification of the time and place
					 of the hearing to the provider or the provider's authorized
					 representative.
(2) Appoint an
					 impartial hearing officer.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.8 - Termination of a Provider

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Department may terminate certification of a skilled nursing facility or
					 intermediate care facility provider prior to the expiration date of the
					 certification upon those grounds specified in Welfare and Institutions Code,
					 Section
					 14123,
					 for the suspension and temporary suspension of a provider from the medical
					 assistance program or as specified in subdivision (b).
(b) A final decision which terminates the
					 certification of a skilled nursing facility or intermediate care facility
					 provider prior to the expiration date of the certification which is entered
					 under the Medicare review procedures specified in Section
					 51048.1 is binding and effective
					 immediately for purposes of Medi-Cal participation and such final decision
					 shall constitute a finding that the termination is necessary to protect the
					 public welfare or the interest of the medical assistance program.
(c) Proceedings to terminate a certification
					 shall be conducted according to Government Code, Section
					 11500, et
					 seq.
Note: Authority cited: Sections
						  10725
						  and
						  14124.6,
						  Welfare and Institutions Code. Reference: Section
						  14123,
						  Welfare and Institutions Code.
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 1.6 - Skilled Nursing Facility and Intermediate Care Facility Certification Appeals Procedure › Section 51048.9 - Remedies Other Than Termination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department may impose a remedy other
					 than or in addition to termination of a provider as provided in Section
					 1919(h)(2) of the
					 Social Security Act. (Section
					 1396 r(h)(2) of Title 42 of the
					 United States Code).
(b) In
					 deciding what remedy to impose, the Department shall select the remedy using
					 the factors and standards contained in subpart F (commencing with section
					 488.400) of part 488 of subchapter
					 E of chapter IV of Title 42 of the Code of Federal Regulations.
(c) The provisions of this Article shall
					 apply to facility appeals of remedies other than termination.
1. New
						section filed 7-18-96 as an emergency; operative 7-18-96 (Register 96, No. 29).
						A Certificate of Compliance must be transmitted to OAL by 11-15-96 or emergency
						language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 7-18-96 order transmitted to
						OAL 11-14-96 and filed 12-31-96 (Register 97, No. 1). Article 2.
						Definitions
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14100.1,
						  Welfare and Institutions Code.
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 2 - Definitions › Section 51050 - Health Care Financing Administration's Common Procedure Coding System

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Health Care Financing Administration's Common Procedure
						Coding System (HCPCS) means a coded listing and description of health care
						services and items prepared and updated annually by theU.S. Health Care
						Financing Administration. HCPCS consists of the Physicians' Current Procedural
						Terminology (CPT), published by the American Medical Association, and other
						codes and descriptions authorized by the Health Care Financing Administration
						to describe services and items not contained in the CPT. HCPCS is used by all
						Medicare and Medicaid Programs nationwide to identify and describe covered
						benefits under their respective programs. To the extent not elsewhere adopted
						in these regulations, HCPCS, and each of its subsequent updates, is herein
						incorporated by reference into these regulations.
EDITORIAL NOTE: Pursuant to the provisions of Title 1 of
						the California Administrative Code, Section
						20, this regulation is not printed
						in full herein. The Health Care Financing Administration's Common Procedure
						Coding System, and each of its annual updates, may be examined at the
						Department of Health Services, Benefits Branch, 714 P Street, Sacramento. It is
						published in two separate documents. Copies of the HCPCS Level II Code Book can
						be purchased from St. Anthony Publishing, Inc., P.O. Box 96561, Washington, DC
						20090. Copies of the CPT can be purchased from the American Medical Association
						by calling 800-621-8335.
1.
						Editorial correction renumbering former Section
						50025.6 to Section
						51050 filed 12-20-83 (Register 83,
						No. 52). For prior history, see Registers 83, No. 48 and 83, No.
						26.
2. Repealer and new section filed 10-1-87; operative 10-31-87
						(Register 87, No. 41).
3. Amendment of section heading and section
						filed 7-28-97 as an emergency; operative 7-28-97 (Register 97, No. 31). A
						Certificate of Compliance must be transmitted to OAL by 11-25-97 or emergency
						language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 7-28-97 order transmitted to
						OAL 11-19-97 and filed 1-6-98 (Register 98, No.
						2).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  433.123, Title 42, Code of Federal
						  Regulations.