Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part III - Dispute Resolution for State-Operated Facilities › Section 12VAC30-70-150 - Methods and standards for establishing payment rates - inpatient hospital care: Dispute resolution for state-operated providers

Current through Register Vol. 40, No. 24, July 15, 2024
§ 1. Definitions.
"DMAS" means the Department of Medical Assistance
					 Services.
"Division Director" means the Director of a division of
					 DMAS.
"State-operated provider" means a provider of Medicaid
					 services which is enrolled in the Medicaid program and operated by the
					 Commonwealth of Virginia.
§ 2. Right to request reconsideration.
A. A state-operated provider shall have the
				  right to request a reconsideration for any issue which would be otherwise
				  administratively appealable under the State Plan by a non-state operated
				  provider. This shall be the sole procedure available to state-operated
				  providers.
B. The appropriate DMAS
				  Division must receive the reconsideration request within 30 calendar days after
				  the provider receives its Notice of Amount of Program Reimbursement, notice of
				  proposed action, findings letter, or other DMAS notice giving rise to a
				  dispute.
§ 3. Informal review. The state-operated provider
					 shall submit to the appropriate DMAS Division written information specifying
					 the nature of the dispute and the relief sought. If a reimbursement adjustment
					 is sought, the written information must include the nature of the adjustment
					 sought; the amount of the adjustment sought; and the reasons for seeking the
					 adjustment. The Division Director or his designee shall review this
					 information, requesting additional information as necessary. If either party so
					 requests, they may meet to discuss a resolution. Any designee shall then
					 recommend to the Division Director whether relief is appropriate in accordance
					 with applicable law and regulations.
§ 4. Division Director action. The Division Director
					 shall consider any recommendation of his designee and shall render a
					 decision.
§ 5. DMAS Director review. A state-operated provider
					 may, within 30 days after receiving the informal review decision of the
					 Division Director, request that the DMAS Director or his designee review the
					 decision of the Division Director. The DMAS Director shall have the authority
					 to take whatever measures he deems appropriate to resolve the dispute.
§ 6. Secretarial review. If the preceding steps do not
					 resolve the dispute to the satisfaction of the state-operated provider, within
					 30 days after receipt of the decision of the DMAS Director, the provider may
					 request the DMAS Director to refer the matter to the Secretary of Health and
					 Human Resources and any other Cabinet Secretary as appropriate. Any
					 determination by such Secretary or Secretaries shall be final.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.