Can You Appeal A PCS Decision?
Yes, You Do Have The Right To Appeal.
If you've received a denial, termination, suspension or reduction of a Medicaid service or authorization of a Medicaid service, then you have a right to appeal that decision. There are a number of reasons why you may want to appeal the decision. Generally, most appeals concern a dispute over the number of hours awarded following the independent assessment for personal care services (PCS).
When Should You File An Appeal?
By law, you must appeal within 30 days of the adverse decision. However, if you're currently getting services, you should appeal within 10 days of notice of the assessment decision. This entitles you to continue to receive services at your current level and ensures that you won't have a gap in Maintenance Of Services (MOS). Note: If your appeal is filed outside the 30-day time frame, no MOS will be given.
How Do You File An Appeal?
You need to send in the appeal (also known as a "hearing request") to the Office of Administrative Hearings (OAH). The OAH is an independent agency that provides prompt and imparital resolution of administrative law contested cases involving citizens and state agencies. Note: The Recipient Hearing Request Form (the appeal) is included with the denial or modification notice that you received from the Department of Health and Human Services. See Filing A Contested Medicaid Case for more information.
What Happens When You Appeal?
OAH will assign a docket number to your case and refer your case to a mediator. Mediation is a voluntary opportunity for the parties to attempt to settle the case between themselves with the help of a neutral, third person and without the formality of the court.
- The mediator will contact you within 5 days of receiving your case to set a time
for the mediation. You may elect to participate in the mediation or to decline
and go directly to a hearing.
- The mediator also contacts Liberty Healthcare Corporation of North Carolina.
Liberty will assign a mediation nurse to your case. During the mediation, Liberty's mediation nurse will review your appeal, the assessment, and collect additional information from the beneficiary/designated representative before determining if any changes to the decision should be made. The nurse will take into consideration all information collected during mediation and then make a determination on hours.
- The mediation must take place within twenty-five (25) days after the case
is received by the Office of Administrative Hearings.
What Happens At The Mediation?
At the mediation, you, the mediator and Liberty's mediation nurse will discuss your case. Your appeal will either be resolved or, if it reaches an impasse (neither party can agree), then your appeal will go forward to a hearing by a Judge.
What Happens At A Hearing?
The hearing date is set by OAH. To every extent possible, this will occur within 55 days of your appeal request submission.
- Typically, a preconference hearing occurs with you or with your representative
and the Attorney for the Attorney Generals' office.
- Your case is either settled then or goes before the Judge for a formal hearing.
- The Judge will render a decision within 20 days of the hearing date.