§440.15. Healthcare provider appeals process
A. A provider shall have a right to the informal and formal appeals processes for determinations made by the recovery audit contractor as provided in this Section.
B. The contractor shall establish an informal appeals process that conforms with all of the following guidelines:
(1) From the date of receipt of the initial findings letter by the contractor, there shall be an informal discussion and consultation period wherein the provider and contractor may communicate regarding any determinations for reasons including but not limited to policies, criteria, and program rules pertinent to the determination.
(2)(a) Within forty-five days of receipt of a notification of an adverse determination from the contractor, a provider shall have the right to request an informal hearing of such findings, or a portion thereof, with the contractor and the Medicaid program integrity division of the department by submitting a request in writing to the contractor.
(b) The informal hearing provided for in this Paragraph shall occur within thirty days of the provider's request.
(c) At the informal hearing, the provider shall have all of the following rights:
(i) The right to present information orally and in writing.
(ii) The right to present documents.
(iii) The right to have the department and the contractor address any inquiry the provider may make concerning the reason for the adverse determination.
(d) A provider may be represented by an attorney or authorized representative at the informal hearing if written notice of representation identifying the attorney or representative is submitted with the request for the informal hearing.
(3) The contractor and medical assistance program integrity division of the department shall issue a final decision related to the informal appeal to the provider within fifteen days of the closure of the appeal.
C. Within thirty days of the issuance of a final decision or determination pursuant to an informal appeal conducted in accordance with Subsection B of this Section, a provider may request an administrative appeal of the final decision by requesting a hearing before the health and hospitals section of the division of administrative law and providing a copy of the appeal to the Medicaid program integrity division of the department.
Acts 2014, No. 568, §1, eff. Aug. 15, 2014.
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