Statutes, codes, and regulations
New Jersey Administrative Code
Title 10 - HUMAN SERVICESChapter 49 - ADMINISTRATION MANUAL
Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS
Section 10:49-9.14 - Provisions for appeals; fair hearings

N.J. Admin. Code § 10:49-9.14

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Current through Register Vol. 56, No. 21, November 4, 2024
Section 10:49-9.14 - Provisions for appeals; fair hearings
(a) Pursuant to N.J.A.C. 10:49-10, Notices, Appeals, and Fair Hearings, providers, Medicaid beneficiaries and NJ FamilyCare-Plan A beneficiaries and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level shall have the right to file for fair hearings.
(b) A provider may be granted a hearing because of the denial of a prior authorization request or issues involving the provider's status; for example, termination, debarment, suspension, and so forth, as described in 10:49-11.1, or issues arising out of the claims payment process.
(c) A Medicaid or NJ FamilyCare-Plan A beneficiary and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level may be granted a fair hearing in accordance with N.J.A.C. 10:49-10 if his or her claim for medical assistance is denied or is not acted upon with reasonable promptness, or because the beneficiary is aggrieved by any other agency action resulting in non-eligibility, denial, termination, reduction or suspension of such assistance. NJ FamilyCare-Plan B, C and all other Plan D beneficiaries shall be afforded the opportunity for grievance review in accordance with N.J.A.C. 10:78-8.
(d) In order to obtain a fair hearing, the provider or the beneficiary shall submit a request in writing to the Medicaid Agent at the address as specified in the notice.
(e) Any nursing facility whose certification or Medicaid Provider Agreement is denied, terminated, or not renewed, may request a hearing in accordance with the appeals procedure described in the Nursing Facilities Services chapter.

N.J. Admin. Code § 10:49-9.14

Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Substituted "beneficiary" and "beneficiaries" for "recipient" and "recipients" throughout; in (d), changed place to send hearing requests; and in (c), substituted "chapter" for "Manual".
Recodified from N.J.A.C. 10:49-9.10 and amended by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Rewrote (a) and (c).
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 with changes, effective 9/21/1998.
Recodified from N.J.A.C. 10:49-9.13 by R.1999 d.294, effective 9/7/1999.
See: 30 N.J.R. 2808(a), 31 N.J.R. 2635(a).
Amended by R.1999 d.211, effective 7/6/1999 (operative August 1, 1999).
See: 31 N.J.R. 998(a), 31 N.J.R. 1806(a), 31 N.J.R. 2879(b).
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
In (a), inserted "Notices, Appeals, and " preceding "Fair Hearings"; rewrote (c).
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In (a) and (c), inserted "and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level"; and in (c), deleted "A" preceding "NJ FamilyCare-Plan B,", inserted "all other Plan" and substituted "beneficiaries" for the final occurrence of "beneficiary".