Md. Code Regs. 10.09.36.09

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.36.09 - Filing Appeal

A. Source of Appeals.

(1) A provider may file an appeal from a proposed Program action to:

(a) Suspend the provider from the Program;

(b) Withhold payment by the Program;

(c) Recover an overpayment;

(d) Remove the provider from the Program;

(e) Disqualify the provider from future participation in the Program, either as a provider or as a person providing services for which Program payment will be claimed; or

(2) A provider shall submit an appeal according to:

(a) COMAR 10.01.03;

(b) State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland;

(c) Health-General Article, §§2-201"2-207, Annotated Code of Maryland; and

(d) COMAR 28.02.01.

(3) A provider may not file an appeal from a Program action to terminate the provider when that action is the result of either:

(a) Termination of the provider or an owner by the federal government or another state Medicaid agency pursuant to 42 CFR § 445.416 ; or

(b) Suspension or termination of the provider's license or certificate by their respective licensing or certification authority.

B. Request for a Hearing.

(1) An appeal of a proposed Program action shall be filed in writing with the Program within 30 days of the date of the notice of the proposed Program action. The Program shall make reasonable accommodation if a provider cannot submit a written request because of a disability.

(2) The Program shall immediately forward a written appeal request to the Office of Administrative Hearings.

(3) The Office of Administrative Hearings shall:

(a) Promptly acknowledge any appeal; and

(b) Notify the provider and the Program in writing of the date, time, and place of the hearing.

C. Effective Date. The proposed Program action shall be effective on:

(1) The date of the proposed Program action notice if the Program:

(a) Determines that the provider poses an imminent threat to public health, safety, or welfare that requires emergency action; and

(b) Notifies the provider of this determination in the proposed Program action notice;

(2) The date specified in the proposed Program action notice if the provider:

(a) Does not request a hearing within 30 days of the date of the notice of the proposed Program action; or

(b) Withdraws in writing or abandons a request for a hearing before the effective date of the proposed Program action;

(3) The first payment date following the date of the Program action notice if the Program action involves withholding payment to the provider because the Program discovered an overpayment to the provider;

(4) The date the administrative law judge renders a decision in favor of the Program if the provider:

(a) Fails to timely file exceptions to the administrative law judge's decision with the Secretary pursuant to §D of this regulation; or

(b) Withdraws in writing or abandons a request for an exceptions hearing before the date of the exceptions hearing; or

(5) The date the Secretary renders a decision in favor of the Program pursuant to COMAR 10.01.03 if any party files exceptions with the Secretary in accordance with §E(1) of this regulation.

D. A Program determination to suspend payments due to a credible allegation of fraud shall be effective immediately unless the Department determines, consistent with 42 CFR § 455.23, that a good cause exception to immediate suspension exists.

E. Exceptions and Outcomes.

(1) A party may seek additional administrative review of the administrative law judge's decision by filing in writing exceptions with the Secretary within 30 days of the date of the administrative law judge's decision pursuant to COMAR 10.01.03.

(2) If the Secretary's decision is favorable to the Program, the Program may:

(a) Immediately implement the proposed Program action; and

(b) Institute recovery procedures against the provider to recoup the cost of any payments made to the provider to the extent the payments were made solely because the provider was permitted to continue to submit claims to the Department because of §C(5) of this regulation.

(3) If the proposed Program action was effective on the date of the notice as provided for in §B(1) of this regulation, the Program shall authorize corrected payments or relief retroactive to the date of the notice if:

(a) The Secretary's decision is favorable to the provider; or

(b) The Program grants the provider the relief the provider requests before the Secretary's decision.

F. Further Appeals. The provider may seek additional administrative review of the Secretary's decision as provided in Health-General Article, §§2-206 and 2-207, Annotated Code of Maryland, and subsequent judicial review as provided in State Government Article, §10-215, Annotated Code of Maryland.

Md. Code Regs. 10.09.36.09

Regulations .09 adopted as an emergency provision effective July 1, 1990 (17:15 Md. R. 1851); adopted permanently effective October 1, 1990 (17:18 Md. R. 2201)
Regulations .09 and new Regulation .09 adopted effective January 24, 2011 (38:2 Md. R. 84); amended effective 45:9 Md. R. 461, eff. 5/7/2018; amended effective 48:12 Md. R. 473, eff. 6/14/2021; amended effective 50:18 Md. R. 794, eff. 9/18/2023