New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 49 - ADMINISTRATION MANUAL
Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS
Section 10:49-9.14 - Provisions for appeals; fair hearings

(a) Pursuant to N.J.A.C. 10:49-10, Notices, Appeals, and Fair Hearings, providers, Medicaid beneficiaries and NJ FamilyCare-Plan A beneficiaries and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level shall have the right to file for fair hearings.

(b) A provider may be granted a hearing because of the denial of a prior authorization request or issues involving the provider's status; for example, termination, debarment, suspension, and so forth, as described in 10:49-11.1, or issues arising out of the claims payment process.

(c) A Medicaid or NJ FamilyCare-Plan A beneficiary and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level may be granted a fair hearing in accordance with N.J.A.C. 10:49-10 if his or her claim for medical assistance is denied or is not acted upon with reasonable promptness, or because the beneficiary is aggrieved by any other agency action resulting in non-eligibility, denial, termination, reduction or suspension of such assistance. NJ FamilyCare-Plan B, C and all other Plan D beneficiaries shall be afforded the opportunity for grievance review in accordance with N.J.A.C. 10:78-8.

(d) In order to obtain a fair hearing, the provider or the beneficiary shall submit a request in writing to the Medicaid Agent at the address as specified in the notice.

(e) Any nursing facility whose certification or Medicaid Provider Agreement is denied, terminated, or not renewed, may request a hearing in accordance with the appeals procedure described in the Nursing Facilities Services chapter.