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Assessing Eligibility for the North Carolina Medicaid Personal Care Services

Frequently Asked Questions on Appeals & Mediation

Q. My client received a "Notice of Decision" that indicated a reduction or denial of services. What information is included in that notice?

A. The following is included.

  • Why the service was denied, reduced or terminated
  • Citations and website addresses for regulations supporting the adverse action
  • Information on how to appeal the decision
  • The effective date of the adverse decision
  • Contact information for someone who can answer questions about the decision in the case

Q. My client does not agree with the reduction of hours indicated in the "Notice of Decision" that he/she received in the mail. How should my client initiate an appeal?

A. To request an appeal, the beneficiary must complete the "Request for Hearing" form found in the Notice of Decision letter. This form must be submitted within 30 days from the date on the letter in order to maintain their current service hours. The instructions regarding where to send the appeal form are included in the notice.

Q. Who will contact my client after he/she submits the "Request for Hearing" form?

A. where's that form?

Q. What happens during mediation?

A. Mediation is conducted over the phone or in person with the beneficiary (or representative), a representative of the Division of Medical Assistance (DMA) and a mediator present. The mediation process is voluntary, confidential, and legally-binding. During the mediation, the beneficiary's assessment, needs/status, and service hours are discussed. After this discussion a decision is made, which may support the denial/reduction, approve service, or increase service. A reassessment of the beneficiary may be conducted as part of the mediation decision. If the beneficiary agrees with the mediation decision, the appeal will be resolved at this point and the mediation decision will be implemented. If the beneficiary does not accept the mediation decision, the beneficiary may proceed to hearing.

Q. A new client, who did not previously receive PCS service, received a Notice of Decision that denied PCS services. Should my agency provide services to this client during the appeal process?

A. No. New program applicants do not receive Maintenance of Service (MOS) during the appeals process. Service is not authorized for this client.

Q. My client submitted an appeal within 10 days of the date of the "Notice of Decision" letter. When will Maintenance of Service (MOS) begin?

A. If the appeal is filed with Office of Administrative Hearings (OAH) within 10 calendar days from the date of the Notice of Decision, authorization of service will be continued at the previous hours (the hours authorized prior to the date on the letter not to exceed 80 hours per month). In this case, there will be no lapse in service.

Q. My client submitted an appeal within 30 days of the date of the "Notice of Decision" letter, but more than 10 days after that date. When will Maintenance of Service (MOS) begin?

A. If the appeal is filed more than 10 calendar days from the date of the Notice of Decision, but within 30 days, authorization of Maintenance of Service (MOS) will be interrupted from the effective date of the Notice of Decision until the date the appeal request is received by Office of Administrative Hearings (OAH). Services will be authorized effective the date OAH receives the appeal request.

Q. My client submitted an appeal more than 30 days from the date of the "Notice of Decision" letter. When will Maintenance of Service (MOS) begin?

A. This client will not be authorized for Maintenance of Service (MOS), as the appeal was submitted more than 30 days after the date of the "Notice of Decision". If the client has appealed a denial, services are not authorized for this client. If the client has appealed a reduction of service, the client will not be eligible for MOS at the previous service level, but will continue to have authorization at the reduced level of service.

Q. I have a client who wishes to change providers while on Maintenance of Service (MOS) during the appeals process. When will Maintenance of Service begin for the new provider?

A. The Maintenance of Service (MOS) authorization will be transferred to the new provider. MOS will be effective for the new provider 10 days after the date of the letter.

Q. My client attended the scheduled mediation, but did not accept the mediation offer. What is the next step in the appeals process?

A. For beneficiaries who do not accept the offer of mediation or for those who participate in mediation but are unwilling to accept the hours offered at mediation, a hearing is scheduled with Office of Administrative Hearings (OAH). This hearing will be take place before an Administrative Law Judge by telephone or if the beneficiary prefers, in person. The beneficiary is notified by mail of the date, time, and location of the hearing. Please note that the OAH hearing is required to be completed within 55 days of the receipt of the hearing request by OAH.

Q. My client attended the Administrative Law hearing, when will he/she receive the final decision on the case?

A. The Administrative Law Judge's decision is required to be entered within 20 days of the receipt of the case from Office of Administrative Hearings (OAH).

If the beneficiary chooses to appeal this decision to the Superior Court, an appeal must be submitted within 30 days of the mailing of the final agency decision.

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