Mont. Admin. R. 37.5.310 - ADMINISTRATIVE REVIEW AND FAIR HEARING PROCESS FOR MEDICAL ASSISTANCE PROVIDERS
(1) The following
administrative review and fair hearing process applies to all medical
assistance providers that are aggrieved by an adverse action of the department,
except medical assistance providers appealing eligibility determinations as a
real party in interest.
(2) A
medical assistance provider, other than a medical assistance provider appealing
an eligibility determination as a real party in interest, aggrieved by an
adverse action of the department may request an administrative review. The
request must be in writing, must state in detail the provider's objections, and
must include any substantiating documents and information which the provider
wishes the department to consider in the administrative review. The request
must be mailed or delivered to the Department of Public Health and Human
Services, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 and should be
addressed or directed to the division of the department that issued the
contested determination. The request for administrative review must be received
by the department within 30 days of mailing of the department's written
determination.
(a) Within the 30 days a
provider may request in writing an extension of up to 15 days for submission of
a request for administrative review. The department may grant further
extensions for good cause shown. Requests for further extensions must be in
writing, must be received by the department within the period of any previous
extension, and must demonstrate good cause for the extension.
(b) The provider may also request a
conference as part of the administrative review. If the provider requests an
administrative review conference, the conference must be held at a time
scheduled by the department as provided in ARM
37.5.318(3) through
(3)(c)(ii). If a provider requests a
conference as part of the administrative review, any substantiating materials
the provider wishes the department to consider as part of the review may be
submitted no later than the time of the conference. The conference may be
conducted by the department or its designee and shall be based on the
department's records and determination and the provider's written objections
and substantiating materials, if any.
(c) No later than 60 days following receipt
of the written objections and substantiating materials, if any, or the
conference, whichever is later, the department must mail a written
determination concerning the provider's objections and substantiating materials
and the position the department takes concerning the determination.
(d) A provider must exhaust in a timely
manner the administrative review process provided in this rule before
requesting a fair hearing. A provider that has not exhausted the administrative
review process, including a provider that fails to timely request an
administrative review, is not entitled to a fair hearing before the department
or the board.
(3) In the
event the provider is aggrieved by an adverse department administrative review
determination, the following fair hearing procedures will apply. In addition to
the authority granted in ARM
37.5.313, the hearings officer may
dismiss a fair hearing request if a provider fails to meet any of the
requirements of (3)(a) through (3)(e).
(a)
The written request for a fair hearing must be mailed or delivered to the
Department of Public Health and Human Services, Quality Assurance Division,
Office of Fair Hearings, P.O. Box 202953, Helena, MT 59620-2953.
(b) The request must be signed by the
provider or his designee.
(c) The
fair hearing request must be received not later than the 30th calendar day
following the date of mailing of the department's written administrative review
determination.
(d) The fair hearing
request must contain a short and plain statement of each reason the provider
contends the department's administrative review determination fails to comply
with applicable law, regulations, rules, or policies.
(e) The provider must serve a copy of the
hearing request upon the department's division that issued the contested
determination within three working days of filing the request. Service by mail
is permitted.
(f) The hearings
officer will conduct the fair hearing in accordance with the applicable
provisions of this subchapter at Helena, Montana. The hearing shall be in
person except that the hearing may be conducted by telephone as mutually agreed
by the parties.
(g) The hearings
officer will render a written proposed decision within 90 calendar days of
final submission of the matter to him.
(4) In the event the provider or department
is aggrieved by a hearings officer's proposed decision, the provider or
department may request review by the Board of Public Assistance as provided in
ARM 37.5.331.
(5) The provisions of this rule apply in
addition to the other applicable provisions of this subchapter, except that the
provisions of this rule shall control in the event of a conflict with the other
provisions of this subchapter.
Notes
2-4-201, 53-6-113, MCA; IMP, 2-4-201, 53-2-201, 53-2-606, 53-6-111, 53-6-113, 53-6-141, MCA;
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