Ala. Admin. Code r. 560-X-3-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-3-.03 - Fair Hearing Procedures For Recipients And Providers

(1) The procedures contained herein have been adopted by Medicaid to settle formal complaints of persons who are receiving care under the Medicaid program or who have been denied care under this program because of eligibility standards, or for providers who desire a fair hearing upon denial of a claim for services, out-dated claim and non-renewal or termination of a contract. At the request of a provider, the Commissioner may grant a fair hearing on any other matter pertinent to Medicaid except the following:

a. When Medicaid suspends payments to a provider after Medicaid determines there is a credible allegation of fraud, pursuant to the requirements of 42 C.F.R. § 455.23, the provider shall not be entitled to a fair hearing regarding the suspension of payments;

b. When the Secretary of Health and Human Services determines that a provider must be removed from the program for fraud or abuse.

(2) A complainant, or authorized person may request a fair hearing in writing if he or she is not satisfied with the actions taken.

(3) A written request for a fair hearing or undue hardship, if allowed by law, must be received by Medicaid within 60 days from the date the notice of action is mailed. Medicaid will not accept requests for fair hearings or undue hardship, if allowed by law, which are outside the 60-day limit. A request for an undue hardship, if allowed by law, will not toll the 60 day time limit to request a fair hearing.

(4) In a case in which Medicaid is terminating recipient eligibility, if a hearing request is received within 10 days of the date of the notice of action, benefits may be continued pending outcome of the hearing unless there are unnecessary delays in finalizing the hearing caused by the recipient or the recipient's representative.

(5) In a case in which Medicaid is suspending or terminating a Medicaid provider, if a hearing request is received within 10 days of receipt of the notice of termination, the provider may continue to remain as a Medicaid provider pending outcome of the hearing, unless there are unnecessary delays in finalizing the hearing caused by the provider or the provider's representative.

Ala. Admin. Code r. 560-X-3-.03

Rule effective October 1, 1982. Amended effective April 11, 1985; January 1, 1986. Amended: Filed May 9, 2013; effective June 13, 2013.

Author: William O. Butler.

Statutory Authority: State Plan, Title XIX, Social Security Act; 42 C.F.R. §§ 401, etseq.

The amended version of this section by Alabama Administrative Monthly Volume XXXVI, Issue No. 09, June 29, 2018, file. 6/11/2018 is not yet available.