R30-2. Adjudicative Procedures, R30. Administrative Services, Office of Inspector General of Medicaid Services, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

R30. Administrative Services, Office of Inspector General of Medicaid Services

R30-2-1. Purpose

Latest version.

The purpose of this rule is to describe the procedures to be followed in adjudicative proceedings handled by the office.

R30-2-2. Authority

Latest version.

This rule is authorized by Section 63A-13-602 and Title 63G, Chapter 4.

R30-2-3. Definitions

Latest version.

Terms used in this rule are defined in Section 63A-13-102, in addition:

(1) "agency action" means an adjudicative proceeding initiated by the office under Title 63G, Chapter 4 against a provider, including a:

(a) recovery action seeking repayment of division funds from a provider; or

(b) payment suspension action under Section 63A-13-205 or 42 CFR Section 455.23; and

(2) "ALJ" means an impartial administrative law judge who has been appointed by the inspector general to conduct an adjudicative proceeding according to these rules.

R30-2-4. Agency Action

Latest version.

(1) When the office determines a division payment made to a provider was incorrect or that a provider's payments from the division should be suspended, the office may file a notice of agency action pursuant to Section 63G-4-201.

(2) The notice of agency action and any other documents associated with the agency action shall be mailed by first class postage to the provider's mailing address on file with the department unless the provider notifies the office in writing of an alternative physical or email address to be used for the adjudicative proceedings.

(3) An agency action initiated by the office shall be an informal adjudicative proceeding under Section 63G-4-202.

(4) Unless otherwise provided by these rules, the rules regarding the calculation of time found in Rule 6 of the Utah Rules of Civil Procedure shall be applicable to an action.

(5) After the initiation of an agency action, the ALJ may issue an order of default against a provider pursuant to Section 63G-4-209 if the ALJ finds a provider:

(a) fails to appear or participate in any step of the adjudicative process; or

(b) unreasonably prolongs the adjudicative process without good cause.

R30-2-5. Request for Agency Review

Latest version.

(1) If a provider disagrees with the findings contained in a notice of agency action, a provider may file a written request for review within thirty days from the date of the notice of agency action.

(2) The request for review shall be filed with the office and include:

(a) a fully completed "Request for Review" form provided with the notice of agency action;

(b) a copy of the notice of agency action sent by the office; and

(3)(a) A request for review shall be considered filed on the date it is received by the office as indicated by the date and time:

(i) hand-delivered to the office;

(ii) of the postmark if it is mailed; or

(iii) logged on an email or fax.

(b) If the postmark date is illegible, erroneous, or omitted, the request for review shall be considered filed on the date the office receives it, unless the provider can demonstrate through competent evidence it was mailed before the date of receipt.

(4)(a) If a provider does not request review in a recovery action, a provider shall repay the money sought to be recovered in the notice of agency action within 30 days.

(b) A provider may repay money to the division by:

(i) sending in a check to the address listed in the notice of recovery;

(ii) contacting the office to arrange for a credit adjustment; or

(iii) voiding the original claim paid by the division.

(c) If a provider has not repaid the division within 60 days from the date of the notice of recovery, the office shall issue a final order and request the division initiate a credit adjustment in the amount listed on the notice of recovery.

(5) If a provider does not request review in a payment suspension action, the suspension shall become effective on the date indicated in the notice of suspension.

(6)(a) If a provider does not object to the remedy requested in the notice of agency action after having requested review, the provider may send a withdrawal of the request for hearing to the office.

(b) In response to the provider's withdrawal of the request for hearing, the office shall enter a final order closing the case and canceling any further proceedings.

R30-2-7. Review Process

Latest version.

(1)(a) If a provider requests review of an agency action initiated by the office, the matter shall be set for a settlement conference between the parties.

(b) The purpose of the settlement conference is to give the parties an opportunity to discuss the issues in the case and attempt to resolve the matter without a hearing.

(2) If the parties are able to resolve the matter, the office shall memorialize the resolution reached in writing and send a copy to the provider.

(3)(a) If after negotiation, the parties are unable to resolve the matter, a party may request the matter be set for a prehearing conference with the ALJ.

(b) The purpose of the prehearing with the ALJ is to set the matter for hearing.

(4) A party may be represented by counsel in the agency review process and at a hearing.

R30-2-8. Hearing

Latest version.

(1) Hearings before the ALJ shall be governed by the procedures in Section 63G-4-203.

(2)(a) A provider may have access to relevant information contained in the office's files the office intends to use in an action as provided in Title 63G, Chapter 2.

(b) A provider's right to discovery is limited and does not extend to interrogatories, requests for admissions, requests for the production of documents, requests for the inspection of items, or depositions.

(c) Subpoenas and orders to secure the attendance of witnesses or the production of evidence may be issued by the ALJ when requested by a party or on the ALJ's own motion.

(3) At the conclusion of a hearing, the ALJ shall issue a final order as provided in Section 63G-4-203.

R30-2-9. Reconsideration

Latest version.

(1) A party may seek reconsideration of the ALJ's decision pursuant to Section 63G-4-302.

(2) If a party files a request for reconsideration with the office, the inspector general shall review the request for reconsideration, along with the ALJ's decision, and may:

(a) uphold the ALJ's decision;

(b) reject the ALJ's decision or any portion of the decision, and make an independent determination based upon the record; or

(3)(a) The decision of the Inspector General constitutes final administrative action and is subject to judicial review.

(b) The Inspector General shall send a copy of the final decision to each party, which includes notice of the parties' right to judicial review and the time limits for filing an appeal.