10A NCAC 22H .0101. PURPOSE AND SCOPE

(a)  The purpose of the rules in this Section is to specify the policies and procedures to provide for recipient/applicant or his/her representative requests for an informal appeal of decisions changing a Medicaid recipient/applicant's level of care, denial, termination, suspension, or reduction of prior approval requests for Medicaid covered medical services or for other Medicaid covered medical services.  These policies and procedures do not apply to provider requests for Reconsideration Review of DMA provider post payment review decisions set out in 10A NCAC 22F.

(b)  The rules in this Section apply to decisions made by the Division of Medical Assistance "(DMA)", a Medical Review Independent Professional Review Team "(MR/IPR)", a Prior Approval Unit "(PAU)", other Agencies, or other entities acting as agents of this State agency.

(c)  The decision making body as set out in Paragraph (b) of this Rule shall, within two working days, notify the recipient/applicant in writing of the decision and the following:

(1)           the effective date of the decision denying, terminating, reducing, or suspending a service;

(2)           the reasons for the agency decision;

(3)           the specific regulations that support, or the change in Federal or State law that requires the decision;

(4)           the date Medicaid payment will cease, if applicable; at least 11 days after the date of the notification letter;

(5)           the opportunity for informal and formal appeal of this decision and procedures for requesting such an appeal; and

(6)           the fact that, if appealed, payment for the currently certified level of care or approved service will continue for an eligible Medicaid recipient pending appeal.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 431; 42 C.F.R. 456;

Eff. April 13, 1979;

Amended Eff. May 1, 1990; November 1, 1983; October 4, 1979;

RRC objection due to lack of Authority and ambiguity Eff. October 18, 1995;

Amended Eff. December 11, 1995.

Note

Editor's Note:  Thomas R. West, Administrative Law Judge with the Office of Administrative Hearings, declared Rule 10 NCAC 26I .0101(codified as 10A NCAC 22H .0101 effective July 1, 2003) void as applied in Linda Allred, Petitioner v. North Carolina Department of Human Resources, Division of Medical Assistance, Respondent (90 DHR 0940).