Coronavirus (COVID-19) Provider Appeals

The following changes have been made in response to the COVID-19 pandemic.

Medicaid:

Provider Appeals Pursuant to the Governor’s Declaration of a State of Emergency issued on March 12, 2020 (Executive Order 51), the DMAS Director is authorized to waive state requirements and regulations. DMAS is exercising its authority for deadlines that govern provider appeals that are specified in the Code of Virginia and DMAS’ provider appeal regulations.  The provider appeals process will follow its current process with the below changes:
  • COVID-19 Hardship Exemption
    • Providers affected by the COVID-19 emergency can request a hardship exemption to the normal deadline to file an appeal. The provider’s request for an informal appeal or formal appeal must state an exemption is being requested and the reason for the exemption.
    • Virginia Premier will accept provider appeals as timely filed if a hardship is indicated on the appeal request.
  • Time Limits
    • Appeal deadlines have been extended to the period of the declaration of emergency after the appeal has been filed; e.g. if the declaration of emergency lasts 50 days, the appeal deadline is extended 50 days. This applies to the following formal and informal appeal deadlines.
  • All informal fact-finding conferences and formal hearings will be conducted by telephone during the period of emergency.

Formal Appeals

  • Hearing date
  • Post-hearing briefs
  • Recommended decision
  • Exceptions
  • Final agency decision

Informal Appeals

  • Case summary
  • Informal-fact-finding conference (IFFC)
  • Document submission after IFFC
  • Informal appeal decision

Fair Hearings and Appeals 

Client Appeals  

DMAS previously noted that it was seeking federal authority to extend the timeframe to file client appeals during the period of emergency. The federal government has authorized DMAS to extend the deadline to request a State Fair Hearing. If an appeal had a filing deadline during the period of emergency or an adverse action was issued during the period of emergency, and the individual did not file the appeal within the normal deadline, DMAS will not request good cause and the appeal will be processed as if it was timely received. 

Medicaid members who are enrolled in a Managed Care Organization (“MCO”) must continue to exhaust the MCO’s internal appeal process before appealing to DMAS. However, the federal government has authorized DMAS to reduce the time period for the MCO to issue an internal appeal decision. DMAS is exercising this authority during the emergency by requiring the MCO to issue the internal appeal decision within 14 calendar days of receipt of the appeal request. If the MCO’s decision is not issued within the 14-day period, the appeal is deemed exhausted and the enrollee can appeal to DMAS.

Both federal and state regulations afford a right to representation in the appeal as long as there is written authorization by the beneficiary, applicant, guardian, or power of attorney. To the extent possible, appeal requests should include the beneficiary’s or applicant’s written authorization for the representative to pursue the appeal or the guardianship/power of attorney paperwork. If the authorization is not submitted with the appeal request, DMAS will request that information. In instances where written authorization is not possible, DMAS will accept appropriate verbal authorization. If neither written nor verbal authorization is received, DMAS will proceed with the appeal, but only by communicating with the beneficiary or applicant about the appeal.

Provider Appeals 

As noted in the Medicaid Memo issued March 19, 2020, providers affected by the COVID-19 emergency may request an extension to the deadline to file an informal or formal appeal. The request for the extension can be submitted prior to filing the appeal or in the appeal request. Additionally, DMAS has extended deadlines after an appeal has been filed for an additional time period equal to the total number of days of the emergency. This will be calculated by adding the total number of days that the emergency was in effect to the applicable deadline. The Informal Appeals Agent or formal appeal Hearing Officer can set specific earlier deadlines if warranted under the circumstances of the appeal.

Medicare:

There will be no time limits for filing an appeal during the Virginia State of Emergency. Similarly, if an appeal is missing information, we will continue to process it as a complete appeal and there will be no time limit for you to provide the missing information to us. However, if the request includes an incomplete Appointment of Representative form, then we will only be able to communicate information about the appeal with the member.

Individual and Family:

There will be no time limits for filing an appeal during the Virginia State of Emergency. Similarly, if an appeal is missing information, we will continue to process it as a complete appeal and there will be no time limit for you to provide the missing information to us. However, if the request includes an incomplete Appointment of Representative form, then we will only be able to communicate information about the appeal with the member. 

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