Mont. Medicaid Hospice Policy Manual, Policy 302

REQUIREMENT

Any Medicaid provider or Medicaid member may appeal any

adverse action made by the Department which is felt to have

affected the amount or scope of Medicaid payments received

and/or amount or scope of Medicaid services.

ADVERSE ACTION

Examples of an adverse action that involves a member include:

1. An action by the Department denying, suspending,

reducing or terminating benefits of a member, or an

action by the Department demanding repayment of or

to recover an overpayment of benefits to a member;

and

2. An action by the Department establishing conditions

on the manner or form of benefits, including restrictive

benefits or protective payments, or establishing

conditions for the receipt of benefits, including work

requirement.

Examples of adverse action that involves a provider agency

provider include:

1. An action by the Department to deny, suspend,

reduce, revoke, or terminate licensure, registration,

certification, or enrollment of a provider or to fail to

renew certification, enrollment, licensure, or the

registration certificate of a provider who has applied

for renewal;

2. An action by the Department establishing the rate of

reimbursement for a provider or denying in whole or in

part a provider’s claim for services or items; and

REQUESTING

FAIR HEARINGS

CONDUCTING

FAIR HEARINGS

BENEFITS

ADMINISTRATIVE

REVIEW

3. An action by the Department demanding repayment

of an overpayment made to a provider, or to impose a

penalty or sanction against a provider or a provider

agreement for the Medicaid program.

A member or provider agency must request a hearing in writing and

mail the request to Office of Fair Hearings, P.O. Box 202953,

Helena, MT 59620-2953.

1. A member’s fair hearing request must be received in

writing within 90 days from the date of mailing of the

notice.

2. A provider agency’s fair hearing request must be

received in writing within 30 days from the date of

mailing of the notice.

The Department’s Hearings Officer conducts Fair Hearings.

Decisions by the Hearings Officer are binding and must conform to

federal and state laws, regulation or policy, and must be based

exclusively on evidence and other material introduced at the

hearing. A Fair Hearing will be preceded by an administrative

review of the action.

Benefits provided to a claimant pending a hearing decision are

subject to repayment by the claimant if the adverse action is

sustained.

Upon the request for a hearing by a member or a provider agency,

the Department shall conduct an administrative review with the

purpose of resolving the case and avoiding an unnecessary

hearing. The review may be conducted in person or by telephone.

In person reviews shall be conducted at a place designated by the

reviewer and reasonably convenient to the member or as

designated by the hearing officer.

An administrative review includes the following:

1. An informal conference with the Department; and

2. The preparation of an administrative review report;

which includes a review of relevant facts and legal

authority and circumstances involved in the adverse

action by the Department.

The Department representative designated to conduct the

administrative review may schedule the administrative review and

must notify the member or provider agency of the date, time, and

place of the conference. If the member or provider agency cannot

appear at the date and time set for the conference, the member or

provider agency must be given a reasonable opportunity to

reschedule the conference.

An adverse action may be reversed or modified by the Department

at any time before, during, or after the administrative review. In this

case, a hearing will not be held unless the member or provider

agency is aggrieved by the modified adverse action and request

that the hearing be held.