Mont. Admin. r. 37.5.307

Current through Register Vol. 23, December 6, 2024

Rule 37.5.307 - OPPORTUNITY FOR HEARING

(1) A claimant who is aggrieved by an adverse action of the department will be afforded the opportunity for a hearing as provided in this chapter.

(2) A request for a hearing is any clear written expression by the claimant or an authorized representative to contest an adverse action, except that a request for hearing concerning food stamp benefits may be oral.

(3) The freedom to request a hearing must not be interfered with in any way. The local office of public assistance or child care resource and referral agency will assist a claimant who seeks help in requesting a hearing.

(4) A request for a hearing by a claimant must be received by the department within 90 days from the date of mailing of notice of the adverse action, except as otherwise provided in these rules.

(5) A hearing request from a claimant must be received in writing within 30 days of the date of mailing of notice of the adverse action regarding:

(a) a department determination of ability to pay for the cost of care in an institution under 53-1-405, MCA;

(b) a nursing facility's transfer or discharge of a nursing facility resident;

(c) a substantiated report of child abuse, neglect, or exploitation; or

(d) a proposal by the department to file a lien under 53-6-171, MCA.

(6) Except for fair hearing requests on a substantiated report, hearing requests must be mailed or delivered to the Office of Fair Hearings, P.O. Box 202953, Helena, MT 59620-2953. Requests for fair hearings on substantiated reports must be mailed to the Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, MT 59620.

(7) Cases in which the sole issue is one of state or federal policy may be consolidated for a single group hearing. Each claimant will be permitted to present their own case.

(8) A provider other than a medical assistance provider who is aggrieved by an adverse action of the department must be granted the right to hearing as provided in this chapter, except as otherwise provided in other department rules.

(a) Except as provided in (2)(b), request for a hearing from a provider must be received by the department in writing within 30 days after the date of mailing of notice of the department's adverse action.

(b) A request for a hearing from a day care facility applicant, licensee, registrant, or legally unregistered provider must be received by the department in writing within ten days after the date of mailing of notice of the department's adverse action denying, suspending, canceling, reducing, modifying, or revoking a legally unregistered provider payment number or a day care license or registration certificate.

(9) Medical assistance providers aggrieved by adverse department actions, other than medical assistance providers appealing eligibility determinations as a real party in interest, will be granted the right to a hearing as provided in ARM 37.5.310.

(a) A medical assistance provider appealing a recipient eligibility determination as a real party in interest is entitled to a hearing according to the procedures and subject to the requirements applicable to claimants except as provided in (3)(b).

(b) It is the provider's responsibility to verify that Medicaid eligibility has been established. If a medical assistance provider receives information from the department indicating that a recipient has not or may not have been determined eligible for Medicaid, as, for example, in an explanation of benefits code on a statement of remittance, the provider must take appropriate action to verify or establish eligibility. A hearing request by the medical assistance provider as a real party in interest regarding the recipient's Medicaid eligibility will not be considered timely if received by the department more than 90 days after the earlier of:

(i) receipt of the information indicating that the recipient has not or may not have been determined Medicaid eligible; or

(ii) adequate notice to the claimant of the adverse action.

(c) A medical assistance provider is not entitled to notice from the department of an adverse action regarding a claimant's eligibility for medical assistance, except that:

(i) if the medical assistance provider has submitted to the county office making the eligibility determination a written request for notice of a determination on a pending application for medical assistance, the county office must mail to the provider a copy of the same notice provided to the claimant; and

(ii) if the medical assistance provider has submitted to the county office responsible to monitor and administer a recipient's ongoing eligibility a written request for notice of termination of eligibility for medical assistance, the county office must mail to the provider a copy of any notice of termination provided to the claimant.

(10) There is no opportunity for hearing under this chapter on departmental activities that are not defined as an adverse action in ARM 37.5.304, unless a right to hearing under this chapter is specifically granted by other department rule. A dispute regarding a contract between the department and a provider or other person or entity is not an adverse action by the department and there is no opportunity for fair hearing concerning such disputes.

Mont. Admin. r. 37.5.307

NEW, 1979 MAR p. 489, Eff. 5/25/79; AMD, 1979 MAR p. 812, Eff. 7/27/79; AMD, 1984 MAR p. 1633, Eff. 11/16/84; AMD, 1985 MAR p. 943, Eff. 7/12/85; AMD, 1992 MAR p. 1496, Eff. 7/17/92; AMD, 1993 MAR p. 3069, Eff. 1/1/94; AMD, 1994 MAR p. 1744, Eff. 7/1/94; AMD, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS & AMD, from SRS, 2000 MAR p. 1653, Eff. 6/30/00; AMD, 2001 MAR p. 1107, Eff. 6/22/01; AMD, 2002 MAR p. 1553, Eff. 5/31/02; AMD, 2004 MAR p. 2409, Eff. 10/8/04; AMD, 2007 MAR p. 47, Eff. 1/12/07; AMD, 2007 MAR p. 2132, Eff. 12/21/07; AMD, 2015 MAR p. 306, Eff. 3/27/2015

AUTH: 2-4-201, 41-3-208, 41-3-1142, 52-2-111, 52-2-112, 52-2-403, 52-2-704, 52-3-304, 52-3-804, 53-2-201, 53-2-606, 53-2-803, 53-3-102, 53-4-111, 53-4-212, 53-4-403, 53-4-503, 53-5-304, 53-6-111, 53-6-113, 53-6-402, 53-7-102, 53-20-305, MCA; IMP: 2-4-201, 41-3-202, 41-3-205, 41-3-1103, 52-2-603, 52-2-704, 52-2-726, 53-2-201, 53-2-306, 53-2-401, 53-2-606, 53-2-801, 53-4-112, 53-4-212, 53-4-404, 53-4-503, 53-4-513, 53-5-304, 53-6-111, 53-6-113, 53-6-402, 53-20-305, MCA