Final Agency Decision No Longer Needed in Medicaid Appeals

This is huge!! Not often in Medicaid administrative law, does the appeal process actually change.  But the appeal process has changed.

In the past, to appeal a decision from North Carolina Department of Health and Human Services (DHHS), you had to file a Petition for Contested Case. The Petition would be heard by an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH).

Once the ALJ rendered a Decision, DHHS would review the ALJ Decision and render a “Final Agency Decision.” Since DHHS is the entity rendering the Final Agency Decision, 9 times out of 10, the Final Agency Decision happened to decide in favor of the Department.

To appeal a Final Agency Decision, you had to request a Judicial Review in Superior Court.  For the Judicial Review,  the Superior Court sits as a Court of Appeals.  Meaning no additional testimony or evidence may be introduced, but each side arguments the legal arguments with the evidence already introduced at OAH.

Not anymore. For dental, behavioral health, and medical authorizations, following an OAH Decision, no Final Agency Decision will be rendered.

This means that any decision made by OAH is the decision that the provider and beneficiary can act upon and that a final agency decision by DHHS is no longer required. 

OAH will mail a copy of the decision via trackable mail (e.g., certified mail, registered mail, USPS trackable mail) to the parties identified on the appeal request form.

How the OAH decision is implemented depends on whether the Decision agreed with DHHS (or the contracting company) or overturned DHHS, in full or in part.  The implementation language is no important, I copied and pasted the language from the

See below:

An OAH decision that upholds the agency action will be implemented no later than three business days from the date the OAH hearing decision is mailed.

Decisions that Reverse the Agency Action (Utilization Review [UR] Contractor Decision) in Part or in Full

  • If the OAH decision or a mediated settlement holds that all or part of the requested services were medically necessary, payment for those services as approved in the OAH decision or settlement will be authorized by Medicaid or its UR contractor within three business days of receipt of the decision. This authorization will remain in effect for 20 prospective calendar days after the date of the decision.
  • If the provider believes that it is medically necessary for the beneficiary to continue the service that has been under appeal, the provider shall submit a prior approval request to the appropriate UR contractor within 15 calendar days of the date of the OAH decision in order to avoid an interruption in services. Upon receipt by the UR contractor of a request for service authorization within the 15 calendar days of the OAH decision, a determination to approve, deny, reduce, or terminate the request will be made within 15 business days – or in accordance with the contractor’s contract with Medicaid. If the request cannot be approved as submitted, authorization for payment will remain in effect without interruption for at least 10 calendar days following the mailing of the notice of decision on the new request for prior approval.
  • If the request is denied or reduced, it will be treated as a timely request for reauthorization and maintenance of service (MOS) pending appeal will apply.

Remember, regardless of the OAH Decision, you still have the right to a judicial review at Superior Court.


About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on March 5, 2013, in Appeal Deadlines, Dentistry Services, Division of Medical Assistance, Health Care Providers and Services, Judicial Review, Legal Analysis, Legislation, MCO, Medicaid, Medicaid Appeals, Mental Health, Mental Illness, NC DHHS, North Carolina, OAH, Outpatient Behavioral Health, Petitions for Contested Cases and tagged , , , , , , . Bookmark the permalink. 4 Comments.

  1. LaTanya Sobczak

    very interesting. thanks for posting!

  2. Yeah–way to go NCGA. Let’s allow folks who know very little about clinical decisions to actually have final say in health care clinical or administrative matters. I have got another great idea–why don’t we allow health care professionals to strike down all judicial rulings and legislation pertaining to health care if they don’t like the rulings or the legislation? It would be the same philosophy employed by the NCGA to give OAH the Final Agency Decision. There is a good reason why all of the other states don’t give the administrative courts Final Agency Decision in Medicaid matters. The reason is that the judges went to law school, not medical school, dental school or any other health care professional school. Maybe someone can tell me why the other 49 states have not bought into this madness and why the heck did CMS agree to allow this foolishness?

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