Overview | Client Appeals | Provider Appeals | Appeal Decision Summaries | Court Review | Link to Virginia Code Commission
The Appeals Division provides a process by which clients and providers can appeal adverse decisions made by the Department or its contractors. The basic function of the appeals process is to give clients and providers an opportunity to be heard after an adverse action has been proposed or taken. The end result of the appeal is a written decision.
The Appeals Division has separate units that handle client appeals and provider appeals. Client appeal decisions and provider appeal decisions can be appealed to court for review of the record.
CLIENT APPEALS UNIT
Client appeals involve issues regarding eligibility and medical services. If a person applies for Medicaid or another program administered by the Department and is determined to be ineligible, that person can request an appeal of the eligibility determination. If a person already eligible for Medicaid or another program administered by the Department is denied a request for a particular medical service or has benefits reduced or terminated, that person can request an appeal of the action taken.
There is one level of administrative appeal, which is an evidentiary hearing before a Department hearing officer. Client appeal decisions can be appealed to court for review of the record.
Title 42 of the Code of Federal Regulations at Subpart E (§431.200 through 431.250) contains the federal requirements for fair hearings for applicants and recipients of Medicaid.
The Department also has regulations addressing client appeals in the Virginia Administrative Code at 12 VAC 30-110-10 through 12 VAC 30-110-380.
PROVIDER APPEALS UNIT
Provider appeals involve issues regarding reimbursement to health care providers for medical services that have already been provided. Provider appeals involve every type of provider with which the Department contracts, including physicians, hospitals, and nursing homes. If a provider has rendered services to a client enrolled in Medicaid or another program administered by the Department and has either been denied reimbursement for the services or has received reduced reimbursement, that provider can request an appeal of the denied or reduced reimbursement.
There are two levels of administrative appeal, first the informal fact finding conference and then the formal evidentiary hearing. The informal fact finding conference is before an informal appeals agent employed by the Department. The evidentiary hearing is before a hearing officer appointed by the Supreme Court of Virginia, and the Supreme Court hearing officer writes a recommended decision for use by the Director of the Department in issuing the final agency decision. Final agency decisions can be appealed to court for review of the record.
The Virginia Code has requirements at Va. Code §2.2-4019 for informal appeals and at Va. Code §2.2-4020 for formal appeals and at Va. Code §32.1-325.1 for both informal and formal appeals. The Department also has regulations addressing provider appeals in the Virginia Administrative Code at 12 VAC 30-20-500 through 12 VAC 30-20-560.
COURT REVIEW
The first level of court review is circuit court review. There is then an automatic right to appeal to the Virginia Court of Appeals. The next level of court review is to the Virginia Supreme Court, but that review must be granted by petition and is not automatic.
The Virginia Administrative Process Act addresses court review of administrative decisions at Va. Code §2.2-4025 through Va. Code §2.2-4030. Part 2A of the Rules of the Virginia Supreme Court addresses appeals pursuant to the Administrative Process Act.
To display and print MS Word documents, you will need to ensure that you have MS Word or must down load the free MS Word reader and install it on your computer. Click here to download the free MS Word reader then follow the installation instructions.
To display and print PDFs, you will need to ensure the free Adobe Acrobat Reader is installed on your computer. Click here to download the free reader from Adobe then follow the installation instructions.