6520 APPEALS

6520.1 At the conclusion of each base year audit or any other required audit, a nursing facility shall receive an audited cost report including a description of each audit adjustment and the reason for each adjustment.6520.2 Within 30 days of the date of receipt of the audited cost report, any nursing facility that disagrees with the audited cost report may request an administrative review of the audited cost report by sending a written request for administrative review to the Agency Fiscal Officer, Audit and Finance, Medical Assistance Administration, Department of Health, 825 North Capitol Street, NE, Suite 5135, Washington, D.C. 20002.6520.3 The written request for an administrative review shall include an identification of the specific audit adjustment to be reviewed, the reason for the request for review of each audit adjustment and supporting documentation.6520.4 MAA shall mail a formal response to the nursing facility no later than forty-five (45) days from the date of receipt of the written request for administrative review pursuant to subsection 6520.2.6520.5 Decisions made by MAA and communicated in the formal response described in subsection 6520.4 may be appealed, within thirty (30) days of the date of MAA's letter, notifying the facility of the decision, to the Office of Administrative Hearings.6520.6 MAA shall issue a rate letter to each nursing facility prior to the initial implementation and at least 30 days prior to the semi-annual rate adjustments set forth in subsection 6508.2 or when rates are rebased pursuant to section 6517. In addition to the required rate letter, MAA shall also issue a transmittal to each nursing facility which sets forth the reimbursement rates of each District nursing facility.6520.7 The rate letter shall include the final per diem payment rate as calculated pursuant to section 6508. The rate letter shall also include the Facility Medicaid case mix index.6520.8 Within fifteen days of the date of receipt of the rate letter issued pursuant to subsection 6520.6, any nursing facility that disagrees with the mathematical calculation of the facility Medicaid case mix index may request an administrative review by sending a written request for administrative review to the Agency Fiscal Officer, Audit and Finance, Medical Assistance Administration, Department of Health, 825 North Capitol Street, NE, Suite 5135, Washington, D.C. 20002.6520.9 The RUGS III classification or CMI score assigned to each resident are not subject to appeal.6520.10 The written request for an administrative review shall include a specific explanation of why

the nursing facility believes the calculation is in error, the relief requested and documentation in support of the relief requested.

6520.11 MAA shall mail a formal response to the nursing facility no later than forty-five (45) days from the date of receipt of the written request for administrative review pursuant to subsection 6520.10.

6520.12 Decisions made by MAA and communicated in the formal response described in subsection 6520.11 may be appealed, within thirty (30) days of the date of MAA's letter notifying the facility of the decision, to the Office of Administrative Hearings.

6520.13 Filing an appeal with the Office of Administrative Hearings pursuant to this section shall not stay any action by MAA to recover any overpayment to the nursing facility.

SOURCE: Final Rulemaking published at 53 DCR 1370 (February 24, 2006).