Pentskiff Interpreting Services v. Department of Health, Division of Medicaid & Health Financing Office of Formal Hearings
2013 UT App 156
| Utah Ct. App. | 2013Background
- Pentskiff Interpreting Services subcontracted with Healthy U (a Utah Medicaid managed care organization) to provide interpretation services for Medicaid enrollees.
- Pentskiff alleged Healthy U failed to pay or fully pay 83 claims and requested a fair hearing from the Utah Department of Health, Division of Medicaid and Health Financing (the Division) on Dec. 21, 2011.
- On Jan. 5, 2012 the Division (following an ALJ recommendation) denied the hearing request for lack of jurisdiction, concluding Pentskiff was not acting solely on behalf of a Medicaid enrollee and the dispute was contractual/payment-related.
- Pentskiff sought judicial review in this Court without first seeking reconsideration from the Division.
- The Division’s rules (as amended April 25, 2011) limit fair hearings to enrollees or providers acting on an enrollee’s behalf with written consent and preclude hearings for managed-care providers to dispute contract terms or claim payments.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Division had jurisdiction to hear Pentskiff’s payment claims | Pentskiff argued it was entitled to a hearing to resolve unpaid claims and that resources (web/manual) permit provider hearings | Division argued Pentskiff wasn’t acting solely on behalf of an enrollee, lacked written consent, and claims are contractual so outside jurisdiction | Court held Division correctly denied jurisdiction; Pentskiff wasn’t acting solely on behalf of an enrollee and dispute is contractual |
| Whether the Division’s change in practice (allowing fewer provider hearings) substantially prejudiced Pentskiff | Pentskiff claimed inconsistent application of rules caused substantial prejudice and sought relief | Division argued it changed practice to conform to amended rules and federal law, offering other fora (small claims/district court) | Court held Pentskiff failed to show specific substantial prejudice and Division’s change was justified by a fair and rational basis |
| Whether Pentskiff qualifies as a "provider" under the rules (affecting standing to seek a hearing) | Pentskiff contended it had a contract with Medicaid and thus is a provider | Division contended Pentskiff only contracted with Healthy U, not the Medicaid program | Court noted resolution of "provider" status unnecessary to disposition; jurisdictional grounds suffice to deny hearing |
| Whether external materials (Division website/Provider Manual) override the administrative rule or Division decision | Pentskiff relied on these materials to support hearing rights | Division argued rules and statutes control; inconsistent materials are without force | Court held rules and law govern; conflicting website/manual materials have no effect when contrary to statute or rule |
Key Cases Cited
- Darvish v. Labor Comm’n Appeals Bd., 273 P.3d 953 (Utah Ct. App. 2012) (agency jurisdiction is a question of law reviewed for correctness)
- Benson v. Peace Officer Standards & Training Council, 261 P.3d 643 (Utah Ct. App. 2011) (inconsistency with prior agency practice reviewed for whether agency provided a fair and rational basis)