Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.417 - Notification of Denial, Reconsideration, and Appeals

Current through Register 1525, July 5, 2024
(A)
Notification of
			 Denial
. The Division or its agent shall notify the recipient, the
			 hospital, and the recipient's attending physician whenever it determines as
			 part of a concurrent review that the hospital admission or stay, or any part
			 thereof, is not medically or administratively necessary. The Division or its
			 agent shall notify the hospital and the recipient's attending physician
			 whenever it determines as part of a concurrent or retrospective review that the
			 hospital stay is or was no longer medically necessary but is or was
			 administratively necessary. The Division or its agent shall notify the hospital
			 and the recipient whenever it determines as part of a concurrent review that a
			 hospital stay is no longer administratively necessary due to the refusal of an
			 appropriate placement.
(B)
Reconsideration
. An agent of the Division under
			 130 CMR 415.000 may provide
			 an opportunity for reconsideration of a determination made by that agent. If a
			 reconsideration is available, notice of the agent's determination will include
			 written notice of: the right to a reconsideration; the time within and manner
			 in which a reconsideration must be requested; and the time within which a
			 decision will be rendered. A hospital, a physician, or a recipient entitled to
			 have a determination reconsidered must request and have a reconsideration
			 determination given before requesting a hearing under 130 CMR
			 415.417(C).
(C)
Appeals
			 to the MassHealth Agency
.
(1) A
			 member may request a fair hearing before the MassHealth agency when the
			 MassHealth agency or its agent determines as the result of a concurrent review
			 that a continued stay is not administratively necessary due to the availability
			 of an appropriate placement as described in
			 130 CMR
			 415.415.
(2) A hospital may request a fair hearing
			 before the MassHealth agency when the MassHealth agency or its agent determines
			 as the result of a concurrent review that an admission or a continued stay, or
			 any part thereof, is not medically necessary but is administratively
			 necessary.
(3) A member or a
			 hospital may request a fair hearing before the MassHealth agency when the
			 MassHealth agency or its agent determines as the result of a concurrent review
			 that an admission or continued stay, or any part thereof, is not medically or
			 administratively necessary.
(4)
			 Written notice of the right to a fair hearing and the manner in which and time
			 within which a hearing must be requested will be provided at the time of the
			 initial determination or of the reconsideration decision by the MassHealth
			 agency or its agent.
(5) A hospital
			 may appeal the determination of the MasHealth agency or its agent as the result
			 of a retrospective review that an admission or a continued stay, or any part
			 thereof, was not medically necessary, was not administratively necessary, or
			 was not medically necessary but was administratively necessary. These appeals
			 are governed by
			 130 CMR 450.000.