Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.20 - Grievances And Fair Hearings Of Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A regional care
			 organization (RCO) with a grievance concerning the Medicaid Agency as addressed
			 in Section
			 22-6-153(e) of
			 the Alabama Code, shall abide by the following procedures.
(2) For the purposes of this rule, a "RCO
			 grievance" means any dispute or claim of a RCO against the Medicaid Agency for
			 which an opportunity for hearing is provided by law or specific contractual
			 provision, excepting disputes or claims for which the State of Alabama, the
			 Medicaid Agency, or their officials, employees, or agents are immune under the
			 constitutions or laws of the State of Alabama and/or the United
			 States.
(3) An RCO shall request a
			 fair hearing with the Medicaid Agency to review an RCO grievance. The request
			 for fair hearing must be in writing and must be filed with the Medicaid Agency
			 within 60 calendar days from the date of the occurrence upon which the RCO
			 grievance is based. Provided, however, this deadline shall not apply to any
			 occurrence discovered upon receipt of an audit, reconciliation or report that
			 provides notice to the RCO of an occurrence that was not previously
			 discoverable in the exercise of reasonable care. In such case the deadline for
			 requesting a fair hearing shall be 60 calendar days from the RCO's receipt of
			 such audit, reconciliation, or report. An RCO's request for a fair hearing with
			 the Medicaid Agency relating to the imposition of a sanction must be in writing
			 and must be filed with the Medicaid Agency within 30 calendar days of the date
			 of the sanction notice. The written request shall include a statement of the
			 factual and/or legal basis for the RCO's dispute or claim and a statement of
			 the relief or action sought. The Medicaid Agency will not accept requests for
			 fair hearings that are outside the filing deadline. The RCO may submit the
			 written request for fair hearing to the Medicaid Agency by mail, hand-delivery,
			 facsimile or electronic mail, and the request must be received by the Medicaid
			 Agency on or before the filing deadline.
(4) Upon filing a written request for a fair
			 hearing, the RCO may also request an informal conference with the Medicaid
			 Agency to seek a resolution of the RCO grievance.
(5) If the RCO grievance is not resolved
			 through informal conference with the Medicaid Agency, the RCO grievance shall
			 be reviewed in a fair hearing before an impartial hearing officer in accordance
			 with the requirements for contested case proceedings under the Alabama
			 Administrative Procedure Act, Section
			 41-22-1
et seq
.
			 The hearing authority for all fair hearings of RCO grievances shall be the
			 Commissioner of the Medicaid Agency, who shall appoint one or more hearing
			 officers to conduct fair hearings and submit findings and recommendations to
			 the Commissioner for final decision on each RCO grievance. The hearing officer
			 shall not have been involved in any way with the RCO grievance in
			 question.
(6) A fair hearing shall
			 be impartially conducted and held at the Medicaid Agency's central office in
			 Montgomery. Written notice of the date, time, place and nature of the fair
			 hearing shall be sent by certified mail to the RCO's address of record and may
			 also be communicated by email or facsimile transmission by the Director,
			 Hearings of the Medicaid Agency, or the designated hearing officer, at least 10
			 calendar days before the hearing is to be held. The notice shall comply with
			 the requirements of Section
			 41-22-12(b).
(7) The RCO may be represented at the fair
			 hearing by legal counsel at its own expense. The RCO may call witnesses and may
			 examine witnesses called by other parties.
(8) The Medicaid Agency shall be responsible
			 for payment of the hearing officer(s) fees and expenses and any court
			 reporter's fees and expenses related to the fair hearing.
(9) All fair hearings shall be conducted in
			 accordance with the provisions of Sections
			 41-22-12 through
			 41-22-19, unless otherwise noted
			 in this rule. Within 30 calendar days of the conclusion of the hearing, the
			 findings and recommendations of the hearing officer shall be submitted to the
			 Commissioner of the Medicaid Agency, who shall make a final decision within 30
			 calendar days of the recommendation. The Medicaid Agency shall promptly send a
			 copy of the final decision to the RCO's address of record by certified
			 mail.
(10) The RCO may seek
			 judicial review of the final decision of the Medicaid Agency in accordance with
			 the provisions of Sections
			 41-22-20 and
			 41-22-21.
(11) This rule shall not be applicable to any
			 grievance relating to a provider contract subject to the provisions of Section
			 22-6-153(g) or
			 Rule No. 560-X-62-.11.
(12) Nothing in this rule is intended to
			 create or establish new causes of action in any court. Nothing in this rule
			 shall be construed as a waiver of any sovereign, qualified, or any other type
			 of immunity.
Author:
Sharon Weaver, Administrator,
				  Administrative Procedures Office
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-6-150 et seq., 41-22-12 through
				  41-22-19.