Opinion ID: 1033240
Heading Depth: 3
Heading Rank: 2

Heading: MCO Appeals Process

Text: The second due process claim is more perplexing as it seems to involve the adequacy of the process provided by non-state actors, the MCOs. This cannot rise to a constitutional violation. See Gonzalez-Maldonado v. MMM Healthcare, Inc., 693 F.3d 244, 248 (1st Cir. 2012) (―Because we hold that [MCOs] are not governmental actors, the appellants‘ constitutional claims necessarily fail . . . .‖). The NJPCA attempts to shoehorn the State into this claim by arguing that the new State policy leaves the FQHCs with no choice when confronted with a wrongful denial of a Medicaid-eligible claim but to go through the internal MCO appeals process, which the NJPCA contends is timeconsuming and biased. But this simply restates the NJPCA‘s substantive Medicaid claim. If an FQHC is entitled to a wraparound payment for a Medicaid-eligible claim notwithstanding the lack of the prior MCO payment, the State‘s refusal to provide the payment is unlawful—no matter what subsequent process is offered. In any event, the adequacy or inadequacy of the internal MCO appellate process cannot be the basis for a procedural due process claim.