Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part XII - Provider Appeals › Section 12VAC30-20-520 - Provider appeals: general provisions

Current through Register Vol. 40, No. 24, July 15, 2024
A. This part governs all DMAS informal and
				  formal provider appeals and supersedes any other provider appeals
				  regulations.
B. A provider may
				  appeal any DMAS action that is subject to appeal under the Virginia
				  Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia),
				  including DMAS' interpretation and application of payment methodologies. A
				  provider may not appeal the actual payment methodologies.
C. DMAS shall transmit all items to the last
				  known address of the provider. It is presumed that DMAS transmits items on the
				  date noted on the item. It is presumed that providers receive items transmitted
				  by United States mail to their last known address within three days after DMAS
				  transmits the item by United States mail. It is presumed that providers receive
				  items transmitted by facsimile, electronic mail , or other electronic
				  submission on the date transmitted. It is presumed that providers receive items
				  transmitted by courier or other hand delivery the date of delivery to the
				  provider's last known address . These presumptions in this section shall apply
				  unless the provider, through evidence beyond a mere denial of receipt,
				  introduces evidence sufficient to rebut the presumption. If a provider requests
				  a copy of an item, the transmittal date for the item remains the date
				  originally noted on the item, and not the date that the copy of the requested
				  item is transmitted. A provider's failure to accept delivery of an item
				  transmitted by DMAS, or a provider's failure to open an item upon receipt,
				  shall not result in an extension of any of the timelines established by this
				  part.
D. Whenever DMAS or a
				  provider is required to file a document, the document shall be considered filed
				  when it is date stamped by the DMAS Appeals Division in Richmond,
				  Virginia.
E. Whenever the last day
				  specified for the filing of any document or the performance of any other act
				  falls on a day on which DMAS is officially closed for the full or partial day,
				  the time period shall be extended to the next day on which DMAS is officially
				  open.
F. Conferences and hearings
				  shall be conducted at DMAS' main office in Richmond, Virginia, or at such other
				  place as agreed upon in writing by DMAS, the provider, and the informal appeals
				  agent for informal appeals. For formal appeals, this agreement shall be between
				  DMAS, the provider, and the hearing officer.
G. Whenever DMAS or a provider is required to
				  attend a conference or hearing, failure by one of the parties to attend the
				  conference or hearing shall result in dismissal of the appeal in favor of the
				  other party.
H. DMAS shall
				  reimburse a provider for reasonable and necessary attorneys' fees and costs
				  associated with an informal or formal appeal if the provider substantially
				  prevails on the merits of the appeal and DMAS' position is not substantially
				  justified, unless special circumstances would make an award unjust. In order to
				  substantially prevail on the merits of the appeal, the provider must be
				  successful on more than 50% of the dollar amount involved in the issues
				  identified in the provider's notice of appeal.
I. Any document that is filed with the DMAS
				  Appeals Division after 5 p.m. Eastern Time shall be date stamped on the next
				  day DMAS is officially open. Any document that is filed with the DMAS Appeals
				  Division after 5 p.m. Eastern Time on the due date shall be untimely.
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.