Article 1. Commencement of Appeals
12VAC30-110-10. Definitions.
The following words and terms, when used in these regulations, shall have the following meanings unless the context clearly indicates otherwise:
"Action" means a denial of, termination of, suspension of, or reduction in covered benefits or services; a denial of or termination, suspension, or reduction in Medicaid eligibility; or an increase in beneficiary liability, including a determination that a beneficiary must incur a greater amount of medical expenses in order to establish income eligibility in accordance with 42 CFR 435.121(e)(4) or 42 CFR 435.831 or is subject to an increase in premiums or cost-sharing charges under Subpart A of 42 CFR Part 447. It also means (i) determinations by a skilled nursing facility or nursing facility to transfer, discharge, or fail to readmit a resident and (ii) an adverse determination made by a state with regard to the preadmission screening and resident review requirements of § 1919(e)(7) of the Social Security Act. It also means the failure to take an application for benefits or to act with reasonable promptness on an application for benefits, on a reported change in circumstances, or on a request for a particular medical service.
"Adverse determination" means a determination made in accordance with § 1919(b)(3)(F) or 1919(e)(7)(B) of the Social Security Act that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.
"Agency" means:
1. An agency or contractor that, on the department's behalf, makes determinations regarding benefits or applications for benefits provided by the department; or
2. The department itself.
"Appellant" means (i) an applicant for or recipient of medical assistance benefits from the department who seeks to challenge an action regarding the applicant's benefits or the applicant's eligibility for benefits and (ii) a nursing facility resident who seeks to challenge a transfer, discharge, or failure to readmit. Appellant also means an individual who seeks to challenge an adverse determination regarding services provided by a nursing facility.
"Burden of proof" means the duty placed upon a party to prove or disprove a disputed fact.
"Date of action" means the intended date on which a termination, suspension, reduction, transfer, or discharge becomes effective. It also means the date of the determination made by a state with regard to the preadmission screening and annual resident review requirements of § 1919(e)(7) of the Social Security Act.
"Day" means calendar day unless otherwise specified or required by law.
"De novo" means that, where a hearing is required, the department's hearing officer will consider all relevant evidence submitted during the appeal in order to make a determination on the issues on appeal, even if the evidence was not previously received by the agency.
"Department" means the Department of Medical Assistance Services.
"Division" means the department's Appeals Division.
"Fail to readmit" means when a nursing facility refuses to readmit a resident who meets the criteria for a bed hold under 42 CFR 438.15.
"Final decision" means a written determination by a hearing officer that is binding on the department, unless modified on appeal or review.
"Hearing" means the de novo evidentiary hearing described in this chapter, conducted by a hearing officer employed by the department.
"Preponderance of the evidence" means that the party with the burden of proof has demonstrated to the hearing officer that their position on the issue in the appeal is more likely valid than not.
"Representative" means an attorney or agent who has been authorized to represent an appellant pursuant to these regulations.
"Send" means to deliver by mail or in electronic format consistent with 42 CFR 431.201 and 42 CFR 435.918.
"State fair hearing" means the entire appeal process for applicants and beneficiaries as set forth in 42 CFR Subpart E.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.7 § 1.1, eff. October 1, 1993; amended, Virginia Register Volume 11, Issue 17, eff. June 15, 1995; Volume 31, Issue 16, eff. May 6, 2015; Volume 34, Issue 6, eff. December 13, 2017; Volume 40, Issue 22, eff. August 1, 2024.
12VAC30-110-130. Request for appeal.
Subpart II
Hearing Officer Review
Article 1
Commencement of Appeals
A. An appeal may be filed by any of the following methods:
1. By telephone;
2. Via email;
3. In person; and
4. Through other commonly available electronic means supported by the agency.
B. Any communication in the formats specified in subsection A of this section from an appellant or his representative that clearly expresses that he wants to present his case to a reviewing authority shall constitute an appeal request. This communication should explain the basis for the appeal.
Statutory Authority
§ 32.1-325 of the Code of Virginia 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.7 § 2.1, eff. October 1, 1993; amended, Virginia Register Volume 34, Issue 6, eff. December 13, 2017.
12VAC30-110-140. Place of filing a Request for Appeal.
A Request for Appeal shall be sent to the Appeals Division.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.7 § 1.11, eff. October 1, 1993; amended, Virginia Register Volume 31, Issue 16, eff. May 6, 2015.
12VAC30-110-150. Filing date.
The date of filing shall be the date the request is postmarked, if mailed, or the date the request is received by the department, if delivered other than by mail.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.7 § 2.3, eff. October 1, 1993.
12VAC30-110-160. Time limit for filing.
A Request for Appeal shall be filed within 30 days of the appellant's receipt of the notice of an action or adverse determination described in 12VAC30-110-70. It is presumed that appellants will receive the notice five days after the agency mails the notice unless the appellant shows that he did not receive the notice within the five-day period. A Request for Appeal on the grounds that an agency has not acted with reasonable promptness may be filed at any time until the agency has acted.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.7 § 1.11, eff. October 1, 1993; amended, Virginia Register Volume 31, Issue 16, eff. May 6, 2015.
12VAC30-110-170. Extension of time for filing.
An extension of the 30-day period for filing a Request for Appeal may be granted for good cause shown. Examples of good cause include the following situations:
1. Appellant was seriously ill and was prevented from contacting the division;
2. Appellant did not receive notice of the agency's action or adverse determination;
3. Appellant sent the Request for Appeal to another government agency in good faith within the time limit;
4. Unusual or unavoidable circumstances prevented a timely filing.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-04-8.7 § 2.5, eff. October 1, 1993; amended, Virginia Register Volume 34, Issue 6, eff. December 13, 2017.
12VAC30-110-180. Provision of information.
Upon receipt of a Request for Appeal, the division shall notify the appellant and his representative of general appeals procedures and shall provide further detailed information upon request.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-04-8.7 § 2.6, eff. October 1, 1993.
12VAC30-110-185. Appeal summary.
A. The agency proposing the action about which the individual requested the state fair hearing shall complete an appeal summary, which shall include:
1. The appellant's name and case name, if different;
2. The appellant's case number, Medicaid identification number, or other identifying information;
3. The agency or contractor responsible for the appellant's case;
4. A summary of the facts surrounding and the grounds supporting the action, the failure to take an application for benefits or to act with reasonable promptness on an application for benefits, a reported change in circumstances, or a request for a particular medical service. The summary of facts must include:
a. A list of the documents reviewed or relied upon, including those reviewed as part of the appeal.
b. A narrative explanation describing the agency's or contractor's position on the action when considering all documentation submitted until the appeal summary is filed. When the action under appeal is for a reduction of termination of existing coverage, the narrative should include an explanation as to what has changed or how the previous approval was made in error.
5. Citations to the statutes, regulations, and specific provisions of the Virginia Medical Assistance Eligibility manual or other policy that support the agency's action; and
6. The adverse benefit determination or the decision notice and any other documents relating to the appeal upon which the agency relied in making its decision.
B. The summary shall be filed with the department's Appeals Division with a complete copy sent to the appellant and the appellant's authorized representative, if applicable, at least five business days before the hearing date.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. August 1, 2024.