Current through Register Vol. 56, No. 18, September 16, 2024
(a) An opportunity
for a fair hearing may be granted to any provider requesting a hearing on any
valid complaint or issue arising out of the Medicaid or NJ FamilyCare claims
payment process, exclusive of HMO claims processing or HMO-provider contract
issues:
1. Such issues shall include, but not
be limited to, denials of prior authorization and denial of claims submitted
for payment.
2. Such requests for
hearing shall be made in writing within 20 days from the date of the notice of
the agency action giving rise to said complaint or issue.
3. For claim denial or payment adjustment,
the 20 days' notice starts from the date in the right hand corner of the
Remittance Advice Claims Status returned to providers with the Remittance
Advice cover page (see the Fiscal Agent Billing Supplement following the second
chapter of each Providers Services Manual regarding the Remittance Advice cover
page and Claims Status explanations and examples). Providers should include a
photocopy of the applicable Claims Status page, highlighting the beneficiary
and applicable edit code(s) when submitting a hearing request.
(b) An opportunity for a fair
hearing shall be granted to all claimants requesting a hearing because their
claims for medical assistance are denied or are not acted upon with reasonable
promptness, or because they believe the Medicaid Agent or NJ FamilyCare-Plan A
program has erroneously terminated, reduced or suspended their assistance. The
Medicaid Agent or NJ FamilyCare program need not grant a hearing if the sole
issue is one of a Federal or State law requiring an automatic termination,
reduction or suspension of assistance affecting some or all claimants. Under
this requirement:
1. A request for hearing
shall be defined as any clear expression (submitted in writing) by claimants
(or someone authorized to act on behalf of claimants) to the effect that they
desire the opportunity to present their case to higher authority;
2. The freedom to make such a request shall
not be limited or interfered with in any way, and the Medicaid Agent or NJ
FamilyCare-Plan A program emphasis shall be on helping claimants to submit and
process their case if needed;
3.
Claimants shall have 20 days from the date of notice of Medicaid Agent or NJ
FamilyCare program action in which to request a hearing;
4. The fair hearing shall include
consideration of:
i. Any Medicaid Agent or NJ
FamilyCare-Plan A program action, or failure to act with reasonable promptness,
on a claim for medical assistance, which includes undue delay in reaching a
decision on eligibility, suspension of assistance or denial of such assistance
in whole or in part;
ii. Medicaid
Agent's or NJ FamilyCare-Plan A program's decision regarding:
(1) Eligibility for medical assistance in
both initial and subsequent determinations;
(2) Amount of medical assistance or change in
such assistance;
5. The Medicaid Agent or DMAHS may respond to
a series of individual requests for fair hearings by arranging for a single
group hearing. A consolidation of cases by the Medicaid Agent or DMAHS may be
allowed only in cases which the sole issue involved is one of Federal or State
law or policy;
6. In all group
hearings, whether initiated by the Medicaid Agent or DMAHS or by claimants, the
policies governing fair hearings shall be followed. Thus, each individual
claimant shall be permitted to present his or her own case and be represented
in accordance with the provisions of
10:49-9.13(a) 3;
and
7. The Medicaid Agent or DMAHS
shall not deny or dismiss a request for a hearing except where it has been
withdrawn by claimant in writing or abandoned.
(c) For purposes of these rules, the right to
a hearing is considered abandoned if claimants or their representative fail to
appear at a scheduled hearing and, within five days after receipt of an inquiry
as to whether they desire any further action on their request, no reply is
received. Refusal of acceptance of a registered letter inquiring into
contemplated further action by claimants shall constitute abandonment effective
the date of refusal.
