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 the 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, email, or
				  other electronic submission on the date transmitted. It is presumed that
				  providers receive items transmitted by courier or other hand delivery on 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. When DMAS or a provider
				  is using the online appeals portal administered by the DMAS Appeals Division,
				  the date stamp will be automatically applied when the item completes
				  transmission to the Appeals Division. When email or facsimile is used, the date
				  stamp will be reflected on the date and time of the transmission. If other
				  means are used, such as postal mail or hand delivery, the date stamp will be
				  applied physically by the DMAS Appeals Division upon receipt.
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 the 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 attorney fees and costs
				  associated with an informal or formal appeal if the provider substantially
				  prevails on the merits of the appeal and the 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.