Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.23 - PROVIDER AND PROVIDER APPLICANT APPEALS

Current through 2024-29, July 17, 2024
1.23-1
General Principles
Any provider or provider applicant that is aggrieved by a
						Departmental action made pursuant to this Manual (excluding emergency
						terminations as referenced in Section 1.19-1 -B) may request an informal review
						within sixty (60) calendar days from the date of receipt of that decision. If
						the deadline falls on a weekend or holiday, the deadline will be extended to
						the next business day. A provider or provider applicant is not aggrieved by,
						and may not request an informal review of, Departmental action issued to,
						directed at, or concerning another provider or provider applicant.
The request for an informal review must be in writing
						(handwritten, typed, or emailed) and addressed to the Director of Compliance,
						Office of MaineCare Services. This review will be conducted by a designated
						Department representative who was not involved in the decision under review.
						The informal review will consist solely of a review of documents in the
						Department's possession including submitted materials/documentation and, if
						deemed necessary by the Department, it may include a personal meeting with the
						provider or provider applicant to obtain clarification of the materials. Issues
						that are not raised by the provider, provider applicant, individual, or entity
						through the written request for an informal review or the submission of
						additional materials for consideration prior to the informal review are waived
						in subsequent appeal proceedings.
The request for informal review may not be amended to
						add further issues.
Requests for informal reviews shall be submitted to
						MaineCare Services or other designated Department representative unless
						otherwise directed by the governing sections of Chapter II or Chapter III of
						this Manual. A written report of the decision resulting from that review will
						be issued to the provider.
A.
Administrative Hearing
A provider or provider applicant must properly request
						an informal review and obtain a decision before requesting an administrative
						hearing. If the provider or provider applicant is dissatisfied with the
						informal review decision, he or she may write the Director of Compliance,
						Office of MaineCare Services, to request a hearing provided he/she does so
						within sixty (60) calendar days from the date of the informal review report on
						the Department's action. If the deadline falls on a weekend or holiday, the
						deadline will be extended to the next business day. Subsequent appeal
						proceedings will be limited only to those issues raised during the informal
						review process.
The DAH shall notify the provider or provider applicant
						in writing of the date, time and place of the hearing, and shall designate a
						presiding officer. Providers and provider applicants will be given advance
						notice of at least twenty (20) calendar days from the mailing date of the
						hearing date. The hearing shall be held in conformity with the
Maine
						Administrative Procedure Act
,
						5 M.R.S. §8001
et seq
. and the Administrative Hearings Regulations.
The presiding officer shall issue a written decision and
						findings of fact to the provider or, pursuant to provisions of the
						Administrative Hearings Regulations,
issue a written recommendation to the Commissioner of
						Health and Human Services. The Commissioner will then make the final decision.
						Legal counsel may represent providers and provider applicants at a hearing and
						may request or subpoena persons to appear at the hearing where they can be
						expected to present testimony or documents relating to issues at the hearing.
If the provider is dissatisfied with the final decision,
						an appeal may be taken to the Superior Court pursuant to the
Administrative Procedure Act
.
B.
Arbitration Alternative
In lieu of the administrative hearing procedure, the
						parties may choose binding arbitration by a qualified arbitrator or panel of
						arbitrators as an alternative
means of resolving a dispute. Both parties must agree to
						this optional method of dispute resolution. The
Maine Uniform
						Arbitration Act
shall regulate the arbitration. A provider's request
						for arbitration must be made within sixty (60) days from the date of receipt of
						the informal review decision prompting the request. Issues for arbitration
						shall be limited to those issues raised during the informal review. The
						arbitrator or panel of arbitrators must be selected and compensated as agreed
						by both parties.
If the parties cannot agree to the terms of arbitration,
						the arbitration alternative will not apply and the normal procedures of
						administrative hearing with the option of appeal to the Superior Court will
						apply. If agreement for arbitration cannot be reached, a timely request for
						arbitration shall be construed as a request for an administrative hearing and
						all other terms of an administrative hearing shall apply. Arbitration is only
						available as an option when the amount in controversy is ten thousand dollars
						($10,000) or less and the subject matter in controversy is assessments,
						recovery or recoupment orders, sanctions, or administrative fines. A provider
						choosing arbitration may waive any right of appeal.