New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48 - APPEAL PROCEDURE › Subchapter 1 - GENERAL PROVISIONS › Section 10:48-1.5 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the meanings as defined in
N.J.A.C.
				  1:1-2.1
or this section unless the
				  context clearly indicates otherwise.
"Administrative hearing" means a proceeding which is
				  conducted by the Office of Administrative Law.
"Administrative review" means a review of the documentary
				  record that is conducted by a review officer appointed by the Assistant
				  Commissioner, following an informal conference concerning a non-contested
				  matter.
"Appeal" means a request made by an authorized person within
				  the established time frames for a review of a disputed decision of the
				  Division, which involves eligibility, placement, or provision of service. The
				  decision shall be a specific action or proposed action, which is identifiable
				  in terms of date, and person(s) making the decision. General complaints or
				  employee grievances shall not be considered appeals.
"Appellant" means the authorized person who may file an
				  appeal with the Division. The authorized person is one of the following:
1. An individual receiving or applying for Division
				  services;
2. The guardian of an individual who is receiving or applying
				  for Division services;
3. An authorized representative of an individual receiving
				  services or applying for services from the Division, a guardian of an
				  individual receiving services or applying for services from the Division.
				  Written verification of status as an authorized representative from the
				  individual or guardian authorizing representation shall be required;
4. A licensee, or his or her authorized representative, of
				  the Department of Human Services that provides services to an individual
				  receiving services from the Division; or
5. An attorney, if written verification of the
				  client/attorney relationship is provided.
"Assistant Commissioner" means the Assistant Commissioner of
				  the Division of Developmental Disabilities.
"Chairperson" means the individual appointed by the
				  Administrative Practice Office to hold an informal conference.
"Contested matter" means an adversarial proceeding, in which
				  the legal rights, duties, obligations, privileges, benefits or other legal
				  relations of specific parties are required by constitutional right or by
				  statute to be determined by an agency by decisions, determinations or orders,
				  addressed to them or disposing of their interests, after opportunity for an
				  agency hearing. (52:14B-2(b),
				  N.J.A.C. 1:1.)
"Days" shall mean calendar days unless otherwise
				  specified.
"Division" means the Division of Developmental
				  Disabilities.
"Division of Medical Assistance and Health Services (DMAHS)"
				  means the agency under the Department of Human Services that is designated in
				  accordance with
				  42 CFR §
										431.10, as the single State agency for the
				  administration of the New Jersey Medicaid program.
"Evidence" is the means from which inferences may be drawn as
				  a basis of proof in the conduct of contested cases, and includes testimony in
				  the form of opinion and hearsay. (1:1-2.1 )
"Fair hearing" means an administrative proceeding to resolve
				  an appeal of a Medicaid waiver-funded service when the service has been denied
				  or will be reduced, suspended, or terminated.
"Final decision" means a decision by an agency head that
				  adopts, rejects, or modifies an initial decision by an administrative law
				  judge, an initial decision by an administrative law judge that becomes a final
				  decision by operation of
52:14B-10
or
				  a decision by an agency head after an administrative review conducted in
				  accordance with this chapter.
"Guardian" means a person or agency who has qualified as a
				  guardian of the person of an incapacitated individual pursuant to court
				  appointment, to make decisions on behalf of the incapacitated individual in
				  those areas where incapacity has been determined by a court as set forth at
3B:12-24.1
.
"Informal conference" means a meeting prior to an
				  administrative review in which the respective parties may informally attempt to
				  resolve the issue which is the subject of appeal.
"Involved parties" means the representative of the appellant
				  and the service component.
"Non-contested case" means those appeals not requiring a
				  contested case proceeding under the statutory definition of contested case at
				  52:14B-2(b).
"Non-waiver services" means those services provided to an
				  individual eligible for Division services for which the Division does not
				  receive reimbursement through the Federal Medicaid program.
"Office of Administrative Law (OAL)" means the independent
				  unit assigned to the Department of the Treasury, which has the authority to
				  hear contested matters.
"Placement" means the out-of-home living arrangement, other
				  than for respite, provided by the Division.
"Recommended decision" means the initial determination in a
				  non-contested case made by a Division administrative review officer. That
				  decision is subject to comments or exceptions by the parties and may be
				  accepted, modified or rejected by the Assistant Commissioner.
"Service component" means the operational unit of the
				  Division (for example, Developmental Center, region, bureau, etc.) from which
				  the disputed matter arises.
"Service plan" means a written, individualized plan,
				  consistent with the requirements of
30:6D-10
through 12,
				  developed by the interdisciplinary team. It is an outcome-based planning tool
				  that, at a minimum, identifies each individualized program, support, or service
				  requested by and provided to the individual, for which the individual
				  demonstrates a need. It identifies the person or agency responsible for its
				  implementation. The complexity of the service plan will vary according to the
				  individual's interests, preferences, and needs. The service plan format must be
				  Division-approved, but can be chosen from various types of plans, as determined
				  by the requirements of the specific program, service, or support and can
				  include, but is not limited to, the following types of plans: individual
				  service plan, individual habilitation plan, or essential lifestyle plan.
"Settlement" means an agreement between parties which
				  resolves disputed matters and may end all or part of the case. Various methods
				  may be utilized to help parties reach agreement, including:
1. Pre-transmission settlement efforts by an agency;
2. Pre-transmission settlement efforts by an administrative
				  law judge at the request of an agency;
3. Mediation by an administrative law judge; and
4. Post-transmission settlement conferences by an
				  administrative law judge. (1:1-2.1 )
"Settlement agreement" means a written agreement that
				  resolves disputed matters in whole or in part. The terms of a settlement
				  agreement shall be written and time limited, or otherwise note when the terms
				  of the agreement have been satisfied. A settlement agreement must be signed by
				  all parties, and is contingent on the signature of the Assistant Commissioner
				  or designee. Unless expressly stated in writing, a settlement agreement shall
				  not:
1. Be construed, interpreted or used as evidence of any
				  admission of fact, law, responsibility, wrongdoing, or liability on the part of
				  any party;
2. Referred to in any subsequent proceedings by any party
				  other than to enforce the express terms of the agreement; and
3. Constitute precedent in any subsequent matter involving
				  the parties or others.
"Settlement conference" means an initial step toward
				  resolving a contested matter prior to transmitting the appeal to the OAL as a
				  contested case.
"Waiver services" means the services available through the
				  authorized Medicaid waiver program in which an individual is enrolled or to
				  which an individual has applied.