210 R.I. Code R. 210-RICR-10-00-1.8

Current through December 3, 2024

Section 210-RICR-10-00-1.8 - Procedure and Notification

A. Notices of Medicaid ineligibility provide applicants and beneficiaries with information about their rights to appeal the agency's decision. These notices also contain specific information about the availability of direct reimbursement if a written appeal is filed and the State's initial decision is overturned as incorrect. The rules governing appeals and hearings are located in "Appeals Process and Procedures for EOHHS Agencies and Programs" (Subchapter 05 Part 2 of this Chapter) regulations.

B. The EOHHS Appeals Office must provide individuals who may qualify with an Application for Reimbursement form to request repayment for medical expenses which they incurred and paid while their appeal was pending.

C. The individual must complete and sign the Application for Reimbursement form and include:

1. A copy of the provider's bill showing date and type of service; and

2. Proof that payment was made by the beneficiary or a person legally responsible for the beneficiary between the date of the erroneous denial and the date of the successful appeal decision. The completed form and required documentation is returned to the appropriate department representative.

D. If either the bill or proof of payment is not included with the Application form, the Medicaid agency representative offers to assist the beneficiary in obtaining the required documentation and sends a reminder notice requesting return of the required information within thirty (30) days from the date of receipt of the Application for Reimbursement form. If all documents are not received within thirty (30) days, or if the documentation provided indicates that medical service or payment was not made between the date of Medicaid denial (or termination) and the date of Medicaid acceptance (or reinstatement), the agency representative denies the request for reimbursement.

E. Otherwise, the agency representative forwards a referral form, attaching the beneficiary's written request for reimbursement and all supporting documentation to the Medicaid agency for a decision on payment. The Medicaid agency is responsible for providing the individual with written notification of the agency's decision and rights to appeal.

210 R.I. Code R. 210-RICR-10-00-1.8

Amended effective 3/17/2024