Current through Register Vol. 48, No. 12, March 22, 2024
a) Provider Eligibility - Purchase of service
providers for whom the Department calculates individual rates (refer to Section
356.30(b)(3)
) or negotiates rates (refer to Section
356.30(c)
) are eligible to appeal their rates, subject to the provisions of this
Section.
b) Notice in Filing of
Appeal - Appeals of the rate reimbursement determination shall be submitted in
writing by the provider to the central office manager responsible for the
administration of reimbursement rates within 60 days after the written notice
by the Department disclosing the provider reimbursement rate. Notice shall be
effective upon the date of mailing to the provider's address. Appeals submitted
more than 60 days after the notice will not be considered by the
Department.
c) Principles of
Appeals Process - The appeals process is designed to allow a provider to
petition for an increase in its reimbursable cost rate in response to
mechanical or clerical errors and/or circumstances which are beyond the control
of the provider, which have an impact upon current operating costs, and which
were not included in the Department's determination of the current allowable
costs. In order to hear an appeal, the provider must have a current signed
contract.
d) Basis for Increase in
Reimbursable Cost - Appeals submitted for the following reasons must be
received by the Department within 60 days after reimbursable rate notice. Any
change in rate, either positive or negative, as a result of the appeal process
will coincide with the effective date of the amendment. Increases in
reimbursable cost can be granted by the Department for the following reasons
and in the following categories:
1)
Mechanical or clerical errors were committed by the Department.
2) There has been a substantial decrease in
external government grants which the Department determines seriously limits the
ability of the agency to deliver required services to Department clients, to
the extent that such revenues were considered available when the Department
approved the reimbursable cost of the provider.
3) The Agency was able to document and
justify that the Department's treatment of its historical cost data resulted in
an inequitable application of the rate-setting process.
4) Mechanical or clerical errors were
committed by the provider on required cost reports and used by the Department
in the calculation of reimbursable costs.
e) Procedures for Filing Appeals - An appeal
for an increase in the reimbursable cost shall be submitted in writing to the
central office manager responsible for the administration of reimbursement
rates with a copy to the Lead Regional Administrator.
1) An appeal shall include but not be limited
to:
A) Identification of the current approved
reimbursable rate;
B) a clear,
concise statement of the reasons for the appeal;
C) a detailed statement of financial,
statistical and related information in support of the appeal;
D) a citation to any statutory or regulatory
requirement pertinent to the appeal; and
E) certification under penalty of perjury by
either the chief executive officer or the financial officer of the provider
that the application and all the information reports, schedules, budgets, books
and records submitted are true, correct and accurate.
2) The Department will not accept or process
an appeal which does not meet the requirements of this Section. In addition, no
appeal can be acted upon unless the provider has a current signed
contract.
3) Any documentation
submitted in support of this appeal which is subsequent to filing of the
appeal, shall contain the same certification described in subsection (e)(1)(E)
above.
f) Review by the
Central Office Manager Responsible for the Administration of Reimbursement
Rates
1) When a provider has filed an appeal,
the central office manager responsible for the administration of reimbursement
rates shall acknowledge in writing that an appeal has been received.
2) The central office manager responsible for
the administration of reimbursement rates will review each appeal for adequacy
of documentation and appropriateness of the request. If required for the
analysis, the Lead Regional Administrator shall provide his/her comments and
recommendations regarding the appeal within 15 days after receipt.
3) The central office manager responsible for
the administration of reimbursement rates may request a meeting at a reasonably
convenient place with representatives of the provider prior to submission of
recommendations to the Director of the Department. The purpose of such meetings
shall include:
A) clarification, formulation,
and simplification of issues;
B)
resolution of matters in controversy;
C) exchange of documents and
information;
D) stipulations of
facts so as to avoid unnecessary presentation before the Director of the
Department;
E) identification of
all documents which the provider or staff intend to present to the Director;
and
F) such other matters as may
aid in the simplification of the evidence and disposition of the
issue.
4) Within 30 days
after receipt by the central office manager responsible for the administration
of reimbursement rates, an appeal which has complied with the principles and
requirements of this Section, or within 15 days after the scheduled meeting
between the central office manager responsible for the administration of
reimbursement rates and the provider, whichever is later, the central office
manager responsible for the administration of reimbursement rates will make a
recommendation to the Director or his designee on this matter.
g) Final Decision of the Director
- The decision of the Director of the Department shall constitute final action
on the appeal. Decision of the Director shall be made within 60 days after
receipt of the appeal by the central office manager responsible for the
administration of reimbursement rates, except that, if the central office
manager responsible for the administration of reimbursement rates requests
additional information, the period shall be extended by the time taken in
providing that information.