Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.5 - FAIR HEARINGS AND CONTESTED CASE PROCEEDINGS › Subchapter 37.5.3 - Formal and Informal Hearing and Appeal Procedures › Rule 37.5.304 - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
For purposes of this subchapter, unless the context requires
				  otherwise, the following definitions apply:
(1) "Adverse action" means:
(a) a failure of the department to provide a
				claimant an opportunity to make application or reapplication for
				benefits;
(b) a failure of the
				department to act with reasonable promptness on a claimant's application for
				benefits;
(c) an action by the
				department denying, suspending, reducing or terminating benefits of a claimant,
				or an action by the department demanding repayment of or to recover an
				overpayment of benefits to a claimant;
(d) an action by the department establishing
				conditions on the manner or form of benefits, including restrictive benefits or
				protective payments, or establishing conditions for the receipt of benefits,
				including a work requirement;
(e)
				an action by the department to deny, terminate, or fail to renew certification
				or a provider agreement for the Medicaid program to any nursing facility or
				intermediate care facility for the mentally retarded;
(f) an action by the department to deny,
				suspend, reduce, revoke, or terminate licensure, registration, certification,
				or enrollment of a provider or to fail to renew certification, enrollment,
				licensure, or the registration certificate of a provider who has applied for
				renewal;
(g) an action by the
				department establishing the rate of reimbursement for a provider or denying in
				whole or in part a provider's claim for services or items;
(h) an action by the department demanding
				repayment of or to recover an overpayment made to a provider, or to impose a
				penalty or sanction against a medical assistance provider under ARM Title 37,
				chapter 85, subchapter 5;
(i) a
				department determination of ability to pay for the cost of care in an
				institution under
				53-1-405,
				MCA;
(j) a department determination
				that a Medicaid applicant or recipient is permanently
				institutionalized;
(k) a
				determination that the department intends to impose a lien upon the applicant's
				or recipient's real property pursuant to
				53-6-171,
				MCA;
(l) an action by the
				department denying or reducing a provider's quality incentive adjustment as
				provided in ARM
				37.80.205;
(m) an action by the department denying or
				reducing a special needs adjustment as provided in ARM 37.80.205;
(n) a department's substantiation
				determination of a report of child abuse, neglect, or exploitation under ARM
				Title 37, chapter 47, subchapter 6;
(o) a determination by the department
				regarding a pharmaceutical manufacturer's rebate due under ARM Title 37,
				chapter 86, subchapter 11;
(p) a
				department determination denying, reducing, terminating, or failing to act upon
				a guardianship subsidy request within one year of the request as provided in
				ARM Title 37, chapter 50, subchapter 11;
(q) a department determination denying,
				reducing, terminating, or failing to act upon an adoption subsidy request
				within one year of the request as provided in ARM Title 37, chapter 50,
				subchapter 11;
(r) a department
				determination denying, reducing, terminating, or failing to act upon an
				application for a license to provide foster care or kinship care; or
(s) an action by the department to:
(i) deny, suspend or cancel a license for a
				swimming pool, spa, or other water feature;
(ii) issue an order immediately closing the
				swimming pool, spa, or other water feature; or
(iii) order corrective action to be taken at
				a swimming pool, spa, or other water feature.