23 Miss. Code. R. 300-2.6 - Beneficiary Appeals
A. The Division of
Medicaid provides beneficiaries the opportunity to request a fair hearing in
order to appeal decisions of:
1.
Eligibility,
2. Denial,
3. Termination,
4. Suspension, or
5. Reduction of Medicaid covered
services.
B. If a
decision is made to reduce, deny, suspend, or terminate covered services
provided to a Medicaid beneficiary, and the beneficiary disagrees with the
decision, the beneficiary and/or the beneficiary's legal representative must
request a hearing within thirty (30) days of the notice of adverse action. See
Part 300, Chapter 2, Rule
2.7, All Hearing Requests, for more
information.
C. The Division of
Medicaid is not required to grant a hearing if the sole issue is a federal or
state law requiring an automatic change adversely affecting some or all
beneficiaries.
D. When an ongoing
Course of Treatment is at issue, services will be maintained at the previous
level during the appeal process.
E.
The Division of Medicaid may deny or dismiss a request for any hearing if the
beneficiary and/or legal representative:
1.
Withdraws the request in writing, or
2. Fails to appear at a scheduled hearing
without good cause.
F.
The case shall be heard by an impartial hearing officer.
G. At the Hearing Officer's discretion, the
case will be evaluated by an appropriate independent review professional in the
same or a similar specialty as would typically manage the case being reviewed,
or another healthcare professional. In no case shall the review professional
have been involved in the initial adverse determination.
H. Before the hearing, the beneficiary and/or
the beneficiary's legal representative will be provided a copy of the case file
that will be used at the hearing in support of the adverse decision.
I. The hearing will be held by telephone
unless, at the hearing officer's discretion, it is determined that an in-person
hearing is necessary.
J. The final
hearing decision shall be rendered by the Executive Director of the Division of
Medicaid based solely on the evidence produced at the hearing and the case
record. The Division of Medicaid must take final administrative action on a
hearing within ninety (90) days from the date the initial appeal request was
received.
Notes
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