10 Colo. Code Regs. § 2505-10-8.050
Current through Register Vol. 47, No. 20, October 25, 2024
Section 10 CCR 2505-10-8.050 - PROVIDER APPEALS8.050.1DEFINITIONS1. Adverse Action means: a. The Department or its designees makes a finding of fact or interpretation of rules that results in a determination that goods or services were not medically necessary; results in identification of overpayments; or results in a reduction in, or denial of, other specific payments under the Medical Assistance program.b. The denial, non-renewal or termination of a Provider agreement.c. The denial of, or request for additional information regarding an application for Medicaid Certification of a Nursing Facility pursuant to Section 8.430.d. The suspension of payments due to a determination of a credible allegation of fraud.2. Mailed means caused to be directed, transmitted, or made available and includes, but is not limited to: a. The use of the United States Postal Service;b. The use of electronic mail (e-mail);c. Making a notice available for retrieval through the Internet or an internet application, as long as notification of the availability is provided through e-mail;d. The use of private courier or delivery services; and e. The use of facsimile (fax) machines.3. Medical assistance shall have the meaning defined in Section 25.5-1-103(5), C.R.S.4. Provider means any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance program to provide medical care, services, or goods and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods.8.050.2NOTICE OF ADVERSE ACTION8.050.2.A. A notice of Adverse Action shall be in writing, Mailed to the Provider, and include the following: 1. A statement of what action the Department intends to take.2. The reasons for the intended action and the applicable regulations in support of that action.3. Information about appeal rights.8.050.2.B. A notice of Adverse Action regarding a nursing facility's rate determination shall include a description of the method of rate calculation, the recommended or proposed audit adjustments with an explanation of adjustments and the final rate established.8.050.2.C. A notice of Adverse Action regarding a determination of overpayment(s) following a review or an audit of a provider shall include the offer of an informal reconsideration of the review or audit findings and notice that no recovery of the overpayment will be implemented until such informal reconsideration, if requested, has been completed.8.050.3PROVIDER APPEALS8.050.3.A. A Provider, other than a nursing facility whose notice of Adverse Action is regarding a rate determination, may appeal a notice of Adverse Action by filing a written appeal within thirty (30) calendar days from the date on the notice of Adverse Action. The appeal shall be filed with the Office of Administrative Courts, Department of Personnel and Administration 1525 Sherman Street, Fourth Floor, Denver, CO 80203.8.050.3.B. The appeal shall specify the basis upon which the Provider appeals the Adverse Action.8.050.3.C. The date of filing the appeal shall be the date the Office of Administrative Courts receives the appeal. Failure to file a timely appeal shall result in dismissal of the appeal.8.050.3.D. No recovery of an overpayment shall be implemented until the appeal process has been completed.8.050.4NURSING FACILITY RATE DETERMINATION APPEALS8.050.4.A. Mandatory Informal Reconsiderations 1. A nursing facility, whose notice of Adverse Action results from its rate determination, may file a written request for informal reconsideration with the Department within thirty (30) days of the date the rate determination letter is mailed or the date that the nursing facility is notified that an electronic copy of the rate determination letter is available for review, whichever is later. The request shall state, with specificity, the adjustments to the cost report the nursing facility wants reconsidered and the nursing facility's position as to each adjustment.2. Requests that do not comply with the requirements of this section shall be considered incomplete and shall be denied.3. When the first rate letter that incorporates a nursing facility's new appraised value is issued or made available electronically to the facility, the nursing facility may file a written request with the Department for informal reconsideration of the appraisal within thirty (30) days of the date on the rate letter or the date that the facility was notified that an electronic copy of the rate letter is available for review, whichever is later. Failure to file an informal reconsideration as set forth in this section shall cause any subsequent reconsideration or appeal of the appraisal at issue to be untimely and the reconsideration or appeal shall be dismissed.4. Failure to file a written request for reconsideration as set forth in this section shall result in a waiver of the right to appeal the Adverse Action. Any issue not presented for informal reconsideration shall not be considered and shall not be appealable to the Office of Administrative Courts.5. At informal reconsideration, the Provider shall not be allowed to present any information that was not submitted during the audit process prior to the issuance of the rate determination. The end of the audit process is defined as the expiration of the proposed adjustment review period as specified in Sections 8.442.3.B and 8.442.3.C.8.050.4.B. The nursing facility may file an appeal with the Office of Administrative Courts of the Department's written decision on the informal reconsideration within thirty (30) days of the date of the written decision. The appeal shall conform to the requirements of Section 8.050.3 . 8.050.4.C. Should the Department not issue a written decision on the informal reconsideration within forty-five (45) days of the Department's receipt of the request for informal reconsideration, the nursing facility may file an appeal with the Office of Administrative Courts within thirty (30) days of the 45th day following receipt of the request for informal reconsideration.8.050.4.D. Notwithstanding the position of the parties, their conduct or statements made during the informal reconsideration process, any subsequent appeal initiated by the nursing facility shall be a de novo proceeding. Neither the Department nor the nursing facility shall be bound by their positions, conduct or statements made as part of the informal reconsideration process. The evidence submitted by the nursing facility and considered at the de novo proceeding, shall be limited to that which was submitted during the audit process prior to the issuance of the rate determination being appealed. No new nursing facility information or documentary evidence shall be admissible at the de novo proceeding.8.050.4.E. The administrative law judge (ALJ) may not under any circumstances alter the appraisal methodology used by the contract appraiser. The ALJ has no authority to consider appeals from providers requesting the use of any method for calculation of depreciation other than the cost valuation system used by the contract appraiser.8.050.4.F. The ALJ may alter the findings of fact, judgments and opinions contained in the appraisal report (e.g. measurements, decisions regarding the depreciation components of effective age and building condition) when supported by the evidence.8.050.5EXEMPTIONS FROM MANDATORY INFORMAL RECONSIDERATION IN NURSING FACILITY RATE DETERMINATION APPEALS8.050.5.A. The following nursing facility rate issues are exempt from mandatory informal reconsideration. 1. In the case of Class I and Class II nursing facilities or private for-profit or non-profit nursing facility Class IV Providers, the nursing facility's right to appeal shall commence on the mailing date of the rate letter setting a rate based on the maximum reasonable cost calculation or on the date the facility array and other data used by the Department in its determination of the maximum reasonable rate is made available to Providers. This appeal period shall then expire thirty (30) days after the commencement date.2. In the case of state-administered Class IV intermediate care facilities for individuals with intellectual disabilities which are not subject to maximum reasonable cost calculations, the nursing facility's right to appeal shall commence on the mailing date of the nursing facility's rate letter setting the final rate based on the facility's actual allowable audited costs as reported on the form MED-13. Such appeal period shall then expire thirty (30) days after the commencement date. The Office of Administrative Courts shall not conduct the appeal hearing. The appeal process shall be resolved by both agencies presenting their position to the Governor's office. The Governor's decision shall be binding on both agencies.3. An appeal of the imposition of a civil money penalty or the denial of a Medicaid payment for a Medicaid-only certified nursing facility's failure to meet federal requirements for participation in Medicaid, shall follow the formal appeal process set forth in Section 8.050.3 . The penalty shall not be enforced or collected until the Department sends a certified letter to the Provider explaining the penalty or the denial of payment. In cases where the Provider appeals the penalty, collection of the penalty shall be suspended until the ALJ adjudicates the appeal.8.050.6INFORMAL RECONSIDERATIONS AND APPEALS OF OVERPAYMENTS RESULTING FROM REVIEW OR AUDIT FINDINGS8.050.6.A. A Provider whose notice of Adverse Action results from a determination of overpayment(s), may file a written request for informal reconsideration with the Department within thirty (30) calendar days of the date of the notice of Adverse Action. 1. Requests made by telephone shall not be accepted.2. The written request shall include: a. The specific overpayments the Provider wants reconsidered;b. The Provider's position as to each overpayment; andc. Documentation that has not already been provided to the Department that substantiates the Provider's position as to each overpayment.3. If a Provider files a written request for informal reconsideration of an Adverse Action and an appeal of the same Adverse Action before a decision has been rendered on the informal reconsideration, the appeal shall control, and the request for an informal reconsideration shall not be acted upon.8.050.6.B. Requests that do not comply with the requirements of this section shall be considered incomplete and shall be denied.8.050.6.C. The Department shall issue a written decision on the informal reconsideration within forty-five (45) calendar days of the date on which the Department received the request for informal reconsideration. The Provider may file a written appeal of the informal reconsideration decision no later than thirty (30) calendar days from the date of the informal reconsideration decision pursuant to Section 8.050.3. 8.050.6.D. If the Department is unable to issue a written decision on the informal reconsideration decision within the time period described at Section 8.050.6.C., then the Department shall notify the Provider of its inability to complete the decision. The Provider may file a written appeal no later than 30 calendar days from the date of the notice stating that the Department is unable to render an informal reconsideration decision pursuant to Section 8.050.3.8.050.6.E. Notwithstanding the position of the parties, their conduct or statements made during the informal reconsideration process, any subsequent appeal initiated by the Provider shall be a de novo proceeding, and neither the Department nor the Provider shall be bound by their prior positions, conduct or statements.8.050.6.F. No recovery of an overpayment shall be implemented until the informal reconsideration and appeals process has been completed.8.050.7CONDUCT OF HEARINGS8.050.7.A. Except as otherwise specifically provided in these rules, the provisions of Section 24-4-105, C.R.S., as amended, shall apply to the conduct of fair hearings. 8.050.7.B. For nursing home appeals regarding appraisals, the ALJ shall not, under any circumstance, alter the appraisal methodology from the most recent Request for Proposal but may alter the finding of fact, judgments and opinions contained in the appraisal report if supported by the evidence.