New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 48 - APPEAL PROCEDURE
Subchapter 1 - GENERAL PROVISIONS
Section 10:48-1.5 - Definitions
The following words and terms, when used in this chapter, shall have the meanings as defined in N.J.A.C. 1:1-2.1 or this section unless the context clearly indicates otherwise.
"Administrative hearing" means a proceeding which is conducted by the Office of Administrative Law.
"Administrative review" means a review of the documentary record that is conducted by a review officer appointed by the Assistant Commissioner, following an informal conference concerning a non-contested matter.
"Appeal" means a request made by an authorized person within the established time frames for a review of a disputed decision of the Division, which involves eligibility, placement, or provision of service. The decision shall be a specific action or proposed action, which is identifiable in terms of date, and person(s) making the decision. General complaints or employee grievances shall not be considered appeals.
"Appellant" means the authorized person who may file an appeal with the Division. The authorized person is one of the following:
1. An individual receiving or applying for Division services;
2. The guardian of an individual who is receiving or applying for Division services;
3. An authorized representative of an individual receiving services or applying for services from the Division, a guardian of an individual receiving services or applying for services from the Division. Written verification of status as an authorized representative from the individual or guardian authorizing representation shall be required;
4. A licensee, or his or her authorized representative, of the Department of Human Services that provides services to an individual receiving services from the Division; or
5. An attorney, if written verification of the client/attorney relationship is provided.
"Assistant Commissioner" means the Assistant Commissioner of the Division of Developmental Disabilities.
"Chairperson" means the individual appointed by the Administrative Practice Office to hold an informal conference.
"Contested matter" means an adversarial proceeding, in which the legal rights, duties, obligations, privileges, benefits or other legal relations of specific parties are required by constitutional right or by statute to be determined by an agency by decisions, determinations or orders, addressed to them or disposing of their interests, after opportunity for an agency hearing. (52:14B-2(b), N.J.A.C. 1:1.)
"Days" shall mean calendar days unless otherwise specified.
"Division" means the Division of Developmental Disabilities.
"Division of Medical Assistance and Health Services (DMAHS)" means the agency under the Department of Human Services that is designated in accordance with 42 CFR § 431.10, as the single State agency for the administration of the New Jersey Medicaid program.
"Evidence" is the means from which inferences may be drawn as a basis of proof in the conduct of contested cases, and includes testimony in the form of opinion and hearsay. (1:1-2.1)
"Fair hearing" means an administrative proceeding to resolve an appeal of a Medicaid waiver-funded service when the service has been denied or will be reduced, suspended, or terminated.
"Final decision" means a decision by an agency head that adopts, rejects, or modifies an initial decision by an administrative law judge, an initial decision by an administrative law judge that becomes a final decision by operation of 52:14B-10 or a decision by an agency head after an administrative review conducted in accordance with this chapter.
"Guardian" means a person or agency who has qualified as a guardian of the person of an incapacitated individual pursuant to court appointment, to make decisions on behalf of the incapacitated individual in those areas where incapacity has been determined by a court as set forth at 3B:12-24.1 .
"Informal conference" means a meeting prior to an administrative review in which the respective parties may informally attempt to resolve the issue which is the subject of appeal.
"Involved parties" means the representative of the appellant and the service component.
"Non-contested case" means those appeals not requiring a contested case proceeding under the statutory definition of contested case at 52:14B-2(b).
"Non-waiver services" means those services provided to an individual eligible for Division services for which the Division does not receive reimbursement through the Federal Medicaid program.
"Office of Administrative Law (OAL)" means the independent unit assigned to the Department of the Treasury, which has the authority to hear contested matters.
"Placement" means the out-of-home living arrangement, other than for respite, provided by the Division.
"Recommended decision" means the initial determination in a non-contested case made by a Division administrative review officer. That decision is subject to comments or exceptions by the parties and may be accepted, modified or rejected by the Assistant Commissioner.
"Service component" means the operational unit of the Division (for example, Developmental Center, region, bureau, etc.) from which the disputed matter arises.
"Service plan" means a written, individualized plan, consistent with the requirements of 30:6D-10 through 12, developed by the interdisciplinary team. It is an outcome-based planning tool that, at a minimum, identifies each individualized program, support, or service requested by and provided to the individual, for which the individual demonstrates a need. It identifies the person or agency responsible for its implementation. The complexity of the service plan will vary according to the individual's interests, preferences, and needs. The service plan format must be Division-approved, but can be chosen from various types of plans, as determined by the requirements of the specific program, service, or support and can include, but is not limited to, the following types of plans: individual service plan, individual habilitation plan, or essential lifestyle plan.
"Settlement" means an agreement between parties which resolves disputed matters and may end all or part of the case. Various methods may be utilized to help parties reach agreement, including:
1. Pre-transmission settlement efforts by an agency;
2. Pre-transmission settlement efforts by an administrative law judge at the request of an agency;
3. Mediation by an administrative law judge; and
4. Post-transmission settlement conferences by an administrative law judge. (1:1-2.1)
"Settlement agreement" means a written agreement that resolves disputed matters in whole or in part. The terms of a settlement agreement shall be written and time limited, or otherwise note when the terms of the agreement have been satisfied. A settlement agreement must be signed by all parties, and is contingent on the signature of the Assistant Commissioner or designee. Unless expressly stated in writing, a settlement agreement shall not:
1. Be construed, interpreted or used as evidence of any admission of fact, law, responsibility, wrongdoing, or liability on the part of any party;
2. Referred to in any subsequent proceedings by any party other than to enforce the express terms of the agreement; and
3. Constitute precedent in any subsequent matter involving the parties or others.
"Settlement conference" means an initial step toward resolving a contested matter prior to transmitting the appeal to the OAL as a contested case.
"Waiver services" means the services available through the authorized Medicaid waiver program in which an individual is enrolled or to which an individual has applied.
