Court Opinion

ID: 4428944
Source: CourtListenerOpinion
Date Created: 2019-08-20 19:15:23.547296+00
Date Added: 2024-06-11T14:23:23.580088
License: Public Domain

NOT FOR PUBLICATION WITHOUT THE
                               APPROVAL OF THE APPELLATE DIVISION
        This opinion shall not "constitute precedent or be binding upon any court." Although it is posted on the
     internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.

                                                         SUPERIOR COURT OF NEW JERSEY
                                                         APPELLATE DIVISION
                                                         DOCKET NO. A-4328-17T2

E.F.,

          Petitioner-Appellant,

v.

DIVISION OF MEDICAL
ASSISTANCE AND HEALTH
SERVICES, and AMERIGROUP,

     Respondents-Respondents.
___________________________

                    Submitted March 18, 2019 – Decided April 2, 2019

                    Before Judges Fasciale and Rose.

                    On appeal from the New Jersey Department of Human
                    Services, Division of Medical Assistance and Health
                    Services.

                    SB2 Inc., attorneys for appellant (Laurie M. Higgins,
                    on the briefs).

                    Gurbir S. Grewal, Attorney General, attorney for
                    respondent Division of Medical Assistance and Health
                    Services (Melissa H. Raksa, Assistant Attorney
                    General, of counsel; Arundhati Mohankumar, Deputy
                    Attorney General, on the brief).
             Pringle Quinn Anzano, PC, attorneys for respondent
             Amerigroup (Michael P. O'Connell, on the brief).

PER CURIAM

       This appeal pertains to a contract dispute between a nursing home (the

provider) and a Managed Care Organization (MCO) (Amerigroup).               The

provider admitted E.F. into the facility and rendered services for approximately

two weeks.1 Amerigroup concluded that the provider breached the contract by

failing to timely notify it about E.F.'s admission. Consequently, Amerigroup

denied the provider's request for payment. Amerigroup explained the appeal

process for disputing payments, and erroneously indicated that one may request

a Medicaid fair hearing.

       The provider did not file an internal appeal. Instead, E.F. executed a

designation of authorized representative (DAR) 2 form and requested a fair

hearing.     The parties moved for summary decision in the Office of

Administrative Law and an Administrative Law Judge (ALJ) concluded that E.F.

received the nursing home services, and that N.J.A.C. 10:74-8.7 prevented the

provider from "balance billing" E.F. Thus, E.F. suffered no harm because she

1
    From January 15, 2017 to January 29, 2017.
2
  E.F.'s authorized representative is a representative of the provider's fiscal
agent.
                                                                        A-4328-17T2
                                       2
could not be billed for any outstanding payments. The ALJ determined that E.F.

lacked standing to appeal Amerigroup's refusal to pay the provider because she

did not have a stake in the matter.

      E.F. now appeals from an April 18, 2018 final agency decision by the

Division of Medical Assistance and Health Services (DMAHS) adopting the

ALJ's decision. DMAHS rejected E.F.'s representative's request to compel

Amerigroup to pay for the services that E.F. received, and concluded that the

dispute had nothing to do with E.F.'s Medicaid eligibility or her need for medical

services. Instead, the dispute pertained to the contract dispute, which it declined

to adjudicate. We affirm.

      On appeal, E.F. argues that (1) Amerigroup violated its own provider

manual (the manual); (2) DMAHS erred by not considering the manual and

evaluating Amerigroup's refusal to pay the provider; and (3) E.F. has standing

to challenge Amerigroup's denial.      We conclude that these contentions are

without sufficient merit to warrant attention in a written decision. R. 2:11-

3(e)(1)(E). We add these brief remarks.

      DMAHS, as an administrative agency within the Department of Human

Services, administers the Medicaid program. N.J.S.A. 30:4D-7. An applicant

can request a fair hearing if denied a Medicaid claim. N.J.A.C. 10:49-10.3(b);

                                                                           A-4328-17T2
                                        3
42 C.F.R. § 431.220(a)(1). E.F. had no right to request a fair hearing because

she had no Medicaid claim.        Instead, the provider should have internally

appealed from Amerigroup's refusal to pay.

      Medicaid beneficiaries – like E.F. – enroll with an MCO, like Amerigroup,

and when the beneficiary receives services, a provider submits a claim for

payment directly to the MCO. Once the beneficiary receives services, that

individual is not responsible for paying the provider. In fact, the provider cannot

bill the beneficiary.    N.J.A.C. 10:74-8.7.     Rather, the provider can seek

collection from the MCO.

      The provider's contract with Amerigroup outlines its internal claims

appeal process. After explaining that E.F. entered the facility without notice or

approval by Amerigroup, and specifically stating that Amerigroup denied the

"stay for non-notification of admission," Amerigroup outlined the health plan

appeal process. According to the contract, the provider may file an informal

appeal, and if dissatisfied, then request arbitration within ninety-days. The

contract states that covered persons are not required to take any action as to the

payment dispute process.

                                                                           A-4328-17T2
                                        4
      But fair hearing rights are different from a provider's right to initiate a

billing dispute. N.J.A.C. 10:49-10.3(b) sets forth opportunities for fair hearings

and states in part that such an opportunity

            shall be granted to all claimants requesting a hearing
            because their claims for medical assistance are denied
            or are not acted upon with reasonable promptness, or
            because they believe the Medicaid Agent or NJ
            FamilyCare-Plan A program has erroneously
            terminated, reduced or suspended their assistance. The
            Medicaid Agent or NJ FamilyCare program need not
            grant a hearing if the sole issue is one of a Federal or
            State law requiring an automatic termination, reduction
            or suspension of assistance affecting some or all
            claimants.

      Here, the dispute does not involve E.F.'s Medicaid eligibility or the denial

of her benefits. Indeed, E.F. received long-term care services for which the

provider cannot bill her pursuant to N.J.A.C. 10:74-8.7. Therefore, DMAHS

determined E.F. lacked standing because she received the services to which she

was entitled. In other words, she lacked any stake in the provider's request for

payment. The dispute is rightfully between the provider and Amerigroup, and

DMAHS correctly dismissed the appeal because it did not involve E.F.'s

beneficiary status.

      Affirmed.

                                                                          A-4328-17T2
                                        5