Case Information
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T HE U TAH C OURT OF A PPEALS
P ENTSKIFF I NTERPRETING S ERVICES ,
Petitioner, v.
D EPARTMENT OF H EALTH D IVISION OF M EDICAID AND H EALTH F INANCING O FFICE OF F ORMAL H EARINGS Respondent.
Memorandum Decision No.
Filed June
Original Proceeding Court
Lonnie Eliason, Attorney Petitioner John E. Swallow Brent A. Burnett, Attorneys Respondent
J UDGE M ICHELE M. C HRISTIANSEN authored Memorandum
Decision, which J UDGES G REGORY K. O RME J. F REDERIC V OROS J R concurred.
CHRISTIANSEN, Judge:
¶1 Services (Pentskiff) seeks judicial review Health, of Health Financing Office Formal Hearings (the Division) denying due We decline disturb decision. subcontracted U Managed Plan (Healthy U) provide U’s non English speaking clients. Utah organization, defined “a health maintenance organization prepaid mental health plan contracts Division] provide mental health v. medical assistance recipients.” Code 14 2(2)(e). alleged has paid, or has paid full, eighty three for services provided Pentskiff. dispute, filed request December 21, On January 5, 2012, Division, recommendation law judge, denied for petitioned for judicial review without seeking reconsideration permitted under Utah section 63G 4 302(1)(b). ¶3 challenges decision, claiming it misapplied relevant law administrative determining lacked jurisdiction hear Pentskiff’s claims. “The issue whether an agency is question law, review for correctness.” Darvish v. Labor Comm’n Appeals Bd. UT App 68, ¶ 16, P.3d 953 (citation internal quotation marks omitted). also that inconsistently interpreted applied amended way Pentskiff. “Claims an agency contrary agency’s practice . . . reviewed determine if an inconsistency justified rational basis.” Benson Peace Officer Standards & Training Council P.3d (omission original) (citation internal quotation marks omitted). Federal require hearing be available for whose assistance denied promptly acted upon. U.S.C. § 1396a(a) (2006) (“A State plan for assistance must . . . provide granting an opportunity for State agency any individual whose claim assistance plan denied acted upon reasonable promptness . . .”); see also C.F.R. 438.400(a)(1) (2012) (requiring “that State plan provide opportunity fair person whose claim assistance acted upon promptly”). Additionally, regulation requires “Medicaid organizations establish internal grievance procedures Medicaid enrollees, or providers on their behalf, challenge the denial coverage of, for, assistance.” 42 C.F.R. § 438.400(a)(3). In order providers their subcontractors access the fair hearing process grievance procedures, they must be “acting on behalf the enrollee the enrollee’s consent.” Id. § 438.402(b)(1)(ii). responsible “implementing, organizing, maintaining [Utah’s] program.” Utah Code Ann. 26 ‐ 18 ‐ 2.1 (LexisNexis 2007). Consistent the and cited above, Code provides a ‐ process providers. See order [1] 2012). (LexisNexis 4 ‐ ‐ 14 ‐ R410 Code Admin. 3, access ‐ process, must be “acting on client [or enrollee].” Id. R410 14 3(2)(i). [2] Otherwise, “has hearing Division].” Id. Also, “may 1. Where differs version currently in effect, cite version code effect at time Pentskiff filed on December 21, 2011. This version went effect on April 25, Admin. R410 ‐ 4 2012). On April 27, 2012, and again on September 27, 2012, were amended part. See id. ‐ (2013). Even though subsequent amendments apply case, variation noted when relevant. Though effect at time January provision deleted rule subsequent
amendments. 3(2)(i) (LexisNexis 2013). current still requires wish access “act[] [an] enrollee’s behalf” allows access only “challenge [to] denial assistance.” 3(2)(d). of hearing to a managed care to dispute terms of or payment of a claim.” Id. R410 4(5). The construed and to mean “providers [like Pentskiff] under contract organizations who are acting solely on behalf of client [who] have written consent from the client to act behalf,” entitled to a hearing before Division. also noted, “This dispute about payment, non payment, of Pentskiff’s U. It falls directly within language rule, Division] therefore prohibited granting [Pentskiff] hearing.” Accordingly, ruled “is hearing [the Division] dispute non payment payment against U.” ¶7 We determine interpretation relevant respect correct. Darvish requesting before Division, was enrollee enrollee’s consent. Rather, seeking payment provided The open “adversely affected action inaction” Division, see Admin. 2(2)(b) (LexisNexis 2012), resulting “denial of assistance,” see 3(2)(d). Here, there claim enrollee’s assistance. intent requesting dispute with current version reads, “[The Division] terms contract. This provision also applies terms rates reimbursement.” 4(5) 2013). Department of Health Healthy Because exclusively behalf of enrollee, before Division. Furthermore, claims against Healthy U arise from contractual dispute, which subject matter outside Division’s 4(5) (stating that “may not grant dispute terms contract payment of claim”). Even though Pentskiff that Healthy U’s eighty three denials of payment do stem problems with contract, nevertheless argues “needs look essence every with the denial, apply contract between Healthy U Pentskiff.” alleges that Healthy U as result “hidden policies U” that “the requirement follow some policies are clearly specified legal nonsense.” Thus, despite Pentskiff’s insistence that stem problems U, facts alleged indicate contractual exactly problem. does claim committed wrongdoing in connection providing Medicaid enrollee. website the Utah Medicaid Provider Manual conflict case. contends these resources Division. Managed Care Plans Health, http://www.health.utah.gov/medicaid/provhtml/managed_care. htm (last visited June 2013); Financing, Provider Manual (2012). extent they contrary applicable law, resources force effect. Ann. 3(2) Supp. 2012) (“The department shall implement program through conformity chapter, Title 63G, Chapter Rulemaking Act, requirements Title XIX, applicable regulations.”). Therefore, because in order to resolve a contract issue with U, we conclude that Division correctly determined that it precluded from exercising jurisdiction over Pentskiff’s claim. acknowledges that it previously allowed and subcontractors, including
Pentskiff, to use to litigate contract claims. However, discontinued practice following a change April argues that it is entitled relief because application amended has resulted substantial prejudice Pentskiff. See Ann. 63G 403(4)(h)(iii) (LexisNexis 2011) (providing that an appellate court relief party is agency action is “contrary agency’s practice, unless agency justifies inconsistency giving facts reasons demonstrate grants only “aggrieved person[s].” Code 3(1) 2012). “Aggrieved person” is defined as “any recipient provider is adversely affected any action inaction [Division] . . health plan.” id. 2(2)(b) (emphasis added). A an organization “has entered into contract program.” 2(22). because it entered written only program. Because provider, argues, “aggrieved person” therefore hearing. contrary, does have direct both State program in particular, provider. Regardless how might Pentskiff’s status provider, would still hear reasons explained above.
Pentskiff v. fair and rational basis inconsistency”). The burden proving prima facie substantial prejudice by preponderance evidence on party seeking judicial review. Benson Peace Officer Standards & Training Council P.3d 643. ¶10 Other than denial its request, identified precisely how was substantially prejudiced Division’s departure from its prior practice. Other forums are available can fully litigate its with Indeed, even advised take “its claims applicable small claims district court.” Nevertheless, even if were demonstrate substantial prejudice, we conclude change Division’s practice fair and rational. The changed its practice conform change its rules. rule change reflects policy shift how administer hearings consistent and law. notes at heart policy shift fact “federal regulations did envision use state’s to adjudicate contractual between its subcontractors.” Compliance regulations governing rational basis to depart prior practice. relief basis change. conclusion, we decline disturb decision dismiss jurisdictional grounds. Also, even if were Division’s departure practice, conclude departure justified rational basis.