TITLE 59: MENTAL HEALTH
CHAPTER IV: DEPARTMENT OF HUMAN SERVICES
PART 132 MEDICAID COMMUNITY MENTAL HEALTH SERVICES PROGRAM
SECTION 132.44 APPEAL OF POST-PAYMENT REVIEW FINDINGS


 

Section 132.44  Appeal of Post-Payment Review Findings

 

a)         If the State agency determines that the provider is not in compliance with the requirements of this Part pursuant to a post-payment review conducted in accordance with Section 132.42, the State agency shall notify the provider in writing of its findings.  The notice shall include:

 

1)         The reason for the State agency's findings;

 

2)         A statement of the provider's right to request a hearing within 20 days after the date of receipt of the written notice;

 

3)         A statement of the legal authority and jurisdiction under which the hearing is to be held; and

 

4)         The address where a request for hearing may be filed.

 

b)         If a provider chooses to appeal the State agency's findings, the provider shall submit a written request for a hearing to the State agency within 20 days after the date of receipt of the written notice. The appeal shall specify the grounds for the appeal.

 

c)         The sole issue at the hearing shall be whether the provider is in compliance with requirements set forth in this Part.

 

d)         The request for hearing shall be filed with, and received by, the State agency within 20 days after the date of the receipt of the written notice to the provider.

 

e)         Hearing process

 

1)         HFS's hearing rules for medical vendor hearings at 89 Ill. Adm. Code 104.200 shall apply, except that the following Sections do not apply to these hearings: 104.204, 104.206, 104.208, 104.210, 104.216, 104.217, 104.221, 104.260, 104.272, 104.273 and 104.274.

 

2)         The State agency shall, within 5 days after receiving the appeal, send a copy of the appeal to the Illinois Department of Healthcare and Family Services Vendor Hearings Section, 401 South Clinton, 6th Floor, Chicago, Illinois 60607.

 

3)         The appellant shall direct all subsequent communications relevant to the hearing to the HFS Vendor Hearings Section.

 

4)         An administrative law judge appointed by HFS shall conduct the hearing.

 

5)         A recommended decision shall be submitted to the Director of Healthcare and Family Services and copies mailed to the parties, in accordance with the provisions of 89 Ill. Adm. Code 104.290.  A copy shall also be mailed to the State agency that referred the matter to HFS.

 

f)         Final administrative decision

The Director of Healthcare and Family Services shall issue a final administrative decision in accordance with the provisions of 89 Ill. Adm. Code 104.295.

 

g)         Judicial review

The final administrative decision shall be subject to judicial review exclusively as provided in the Administrative Review Law [735 ILCS 5/Art. III].

 

h)         A provider shall be liable for reimbursement of bills submitted from the date of the final administrative decision pursuant to this Section if such decision results in an adverse finding for the provider.

 

(Source:  Amended at 36 Ill. Reg. 18582, effective December 13, 2012)