1. A. The agency proposing the action about which the individual requested the state fair hearing shall complete an appeal summary, which shall include:

   1. 1. The appellant's name and case name, if different;
   2. 2. The appellant's case number, Medicaid identification number, or other identifying information;
   3. 3. The agency or contractor responsible for the appellant's case;

   4. 4. A summary of the facts surrounding and the grounds supporting the action, the failure to take an application for benefits or to act with reasonable promptness on an application for benefits, a reported change in circumstances, or a request for a particular medical service. The summary of facts must include:

      1. a. A list of the documents reviewed or relied upon, including those reviewed as part of the appeal.
      2. b. A narrative explanation describing the agency's or contractor's position on the action when considering all documentation submitted until the appeal summary is filed. When the action under appeal is for a reduction of termination of existing coverage, the narrative should include an explanation as to what has changed or how the previous approval was made in error.
   5. 5. Citations to the statutes, regulations, and specific provisions of the Virginia Medical Assistance Eligibility manual or other policy that support the agency's action; and
   6. 6. The adverse benefit determination or the decision notice and any other documents relating to the appeal upon which the agency relied in making its decision.
2. B. The summary shall be filed with the department's Appeals Division with a complete copy sent to the appellant and the appellant's authorized representative, if applicable, at least five business days before the hearing date.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 40, Issue 22, eff. August 1, 2024.