Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-650 - Appeal timeframes

Current through Register Vol. 40, No. 24, July 15, 2024
A. Appeals
				  to the Medicaid state fair hearing process must be filed with the Appeals
				  Division within 120 days of the date of the MCO's final internal appeal
				  decision.
B. It is presumed that
				  appellants will receive the MCO's final internal appeal decision five days
				  after the MCO mails it unless the appellant shows that the appellant did not
				  receive the notice within the five-day period.
C. A request for a state fair hearing on the
				  grounds that the MCO has not acted with reasonable promptness in response to an
				  internal appeal request may be filed at any time until the MCO has
				  acted.
D. The date of filing shall
				  be the date the internal appeal request is received by the MCO, the date the
				  state fair hearing request is received by the Appeals Division, or the postmark
				  date if the state fair hearing request is sent by regular mail.
E. In computing any time period under this
				  chapter, the day of the act or event from which the designated period of time
				  begins to run shall be excluded and the last day included. If a time limit
				  would expire on a Saturday, Sunday, or state or federal holiday, it shall be
				  extended until the next regular business day.
F. DMAS shall take final administrative
				  action within 90 days from the date the member filed an MCO appeal, not
				  including the number of days the member took to subsequently file for a state
				  fair hearing.
G. Exceptions to
				  standard appeal resolution timeframes. Decisions may be issued beyond the
				  standard appeal resolution timeframes when the appellant or the appellant's
				  authorized representative requests or causes a delay. Decisions may also be
				  issued beyond the standard appeal resolution timeframe when any of the
				  following circumstances exist:
1. The
				  appellant or authorized representative requests to reschedule or continue the
				  state fair hearing;
2. The
				  appellant or authorized representative provides good cause for failing to keep
				  a scheduled state fair hearing appointment, and the Appeals Division
				  reschedules the state fair hearing;
3. Inclement weather, unanticipated system
				  outage, or the department's closure prevents the hearing officer's ability to
				  work;
4. Following a state fair
				  hearing, the hearing officer orders an independent medical assessment as
				  described in 12VAC30-120-670 H 1;
5. The hearing officer leaves the state fair
				  hearing record open after the state fair hearing in order to receive additional
				  evidence or argument from the appellant;
6. The hearing officer receives additional
				  evidence from a person other than the appellant or the appellant's authorized
				  representative, and the appellant requests to comment on such evidence in
				  writing or to have the state fair hearing reconvened to respond to such
				  evidence; or
7. The Appeals
				  Division determines that there is a need for additional information and
				  documents how the delay is in the appellant's best interest.