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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWyoming Medicaid Hearing Policy Update | OpenPayer
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    CurrentWyoming Department of HealthPolicy 048.0037.4.03242020

    Chapter 4: Medicaid Administrative Hearings

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    Governs contested Medicaid cases in Wyoming, including hearing rights, adverse-action notices, hearing requests, interim services, hearing procedures, decisions, appeals, and records.

    Policy Summary
    PayerWyoming Department of Health
    PolicyChapter 4: Medicaid Administrative Hearings
    Policy CodePolicy 048.0037.4.03242020
    Change TypeNo material change
    Effective DateMar 24, 2020
    Next Review DateNot specified
    Key ActionAccept a client's hearing request through an authorized method within 20 business days after mailing the adverse-action notice.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    20 daysHearing request deadline
    10 daysAcceptance decision
    40 daysHearing scheduling
    20 daysProposed findings
    10 days

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    Final decision
    10 daysAdvance notice

    Hearing Rights and Appeal Protections

    Right to a Medicaid Administrative Hearing

    A hearing right applies in the following circumstances. The Department must provide notice of an adverse action and explain the applicable hearing rights, request method, representation rights, intended action, effective date, reasons, supporting regulations or legal change, and, when applicable, how benefits may continue during the appeal.

    HEARING RIGHTS

    • ONE of the following applies

      • An applicant's application is denied or is not acted upon within the time frames specified by the Department.
      • A client's eligibility or services are denied, reduced, terminated, or suspended.
      • A provider seeks review of an adverse action after requesting reconsideration as specified in Chapter 16 of the Wyoming Department of Health's Medicaid Rules.
      • A pharmaceutical manufacturer seeks review of an adverse action; pharmaceutical manufacturers have the same hearing rights as providers.

    • NOTICE CONTENT FOR APPLICANTS AND CLIENTS

      • The Department provides notice at the time of any adverse action.
      • The notice explains the individual's right to request a hearing or the circumstances in which a hearing will be granted based on a change in law.
      • The notice states the method for requesting a hearing.
      • The notice explains the right to representation by a legally authorized representative, including a lawyer admitted to practice in Wyoming, a relative, friend, or other spokesperson; the individual must notify the Department in writing if represented.
      • The notice states the intended action, effective date, reason or reasons, and the specific supporting regulations or federal or state law change requiring the action.
      • When applicable, the notice explains the circumstances under which benefits may continue if a hearing is requested under 42 C.F.R. § 431.231.

    • PROVIDER NOTICE CONTENT

      • Following a request for reconsideration, the Department notifies a provider of the right to a hearing at the time of the adverse-action notice, except when issuing a notice of claims payment or denial.
      • The provider notice states the intended action, effective date, reasons, and specific supporting regulations or federal or state law change.
      • The provider notice explains the right to representation by a lawyer admitted to practice in Wyoming.

    Notices, Requests, and Hearing Administration

    Note

    Applicant and Client Adverse-Action Notice

    The Department must provide applicants and clients notice at the time of an adverse action. The notice must explain hearing rights and applicable circumstances, how to request a hearing, representation rights and written-representation notice requirements, and the intended action, effective date, reasons, supporting regulations or legal change, and—when applicable—how benefits may continue under 42 C.F.R. § 431.231.

    • For applicants, mail notice after a final determination.
    • For clients, mail notice at least 10 business days before the effective date.
    • Notice may be mailed at least 5 business days before the effective date when probable client fraud is indicated and, if possible, verified through secondary sources.
    • Notice may be mailed no later than the effective date for specified circumstances, including death, a qualifying written request or disclosure by the client, institutional ineligibility, unknown whereabouts with returned mail, acceptance of benefits in another jurisdiction, a physician-prescribed change in medical care, or certain mental-illness/intellectual-disability preadmission-screening determinations.
    Note

    Provider Adverse-Action Notice

    Key Terms

    Terminology
    Default meaningTerminology used in this chapter has the standard meaning used in health care, Medicaid, and Medicare.
    ExceptionChapter 1 of the Wyoming Department of Health's Medicaid Rules may specify otherwise.
    Applies toTerms used throughout this chapter unless an exception is specified in Chapter 1 of the Department's Medicaid Rules.
    Contested case
    DefinitionA contested case involving Medicaid that is governed by this chapter.
    ScopeThis chapter applies to all contested cases involving Medicaid in accordance with Medicaid rules.
    Exception
    Policy Summary
    PayerWyoming Department of Health
    PolicyChapter 4: Medicaid Administrative Hearings
    Policy CodePolicy 048.0037.4.03242020
    Change TypeNo material change
    Effective DateMar 24, 2020
    Next Review DateNot specified
    Key ActionAccept a client's hearing request through an authorized method within 20 business days after mailing the adverse-action notice.
    SourceLink
    On This Page
    Hearing Rights and Appeal ProtectionsNotices, Requests, and Hearing AdministrationKey Terms

    Following a provider’s request for reconsideration, the Department must notify the provider of the right to a hearing at the time of the adverse-action notice. The notice must identify the intended action, effective date, reasons, supporting regulations or legal change, and the right to representation by a lawyer admitted to practice in Wyoming.

    • This hearing-right notice requirement does not apply when issuing a notice of claims payment or denial.
    • For a denial or reduction of payments, notify the provider after the denial or reduction.
    • For termination, suspension, or another adverse action, provide notice in accordance with Chapter 16 of the Wyoming Department of Health Medicaid Rules.
    Note

    Client Hearing Request

    A client must request a hearing within 20 business days after the Department mails the adverse-action notice.

    • Permitted methods: submit electronically by email, make the request verbally to the Department, mail it by certified mail with return receipt requested, or personally deliver it to the Department.
    Documentation Required

    Provider Hearing Request

    A provider must request a hearing within 20 business days after the Department mails the adverse-action notice.

    • The request must be mailed by certified mail with return receipt requested or personally delivered to the Department.
    • The request must state the reasons for the hearing with specificity.
    • Failure to state the reasons results in dismissal of the request with prejudice.
    Note

    Review and Disposition of Hearing Request

    Within 10 business days after receiving a hearing request, the Department must evaluate it and notify the requesting party in writing whether the request is accepted or rejected.

    • The Department may deny the request if the challenged action is not an adverse action as defined or if the request does not meet the chapter’s requirements.
    • A denial of a hearing request is a final Department decision.
    Denial Risk

    Maintaining Services Pending Appeal

    When the Department has mailed the required notice and a client requests a hearing before the action’s effective date, the Department may not terminate or reduce services until the final decision after the hearing, subject to the stated exception.

    • The exception applies when the Hearing Officer determines at the hearing that the sole issue is federal or state law or policy and the Department promptly informs the client in writing that services will be terminated or reduced pending the final decision.
    • If the adverse action is affirmed, the Department may recover from the client the cost of services or goods furnished solely because services continued under this rule and may recover provider overpayments under 42 C.F.R. § 431.230(b).
    • The Department must reinstate and continue services until a decision is rendered when the action resulted from something other than federal or state law or policy, pursuant to 42 C.F.R. § 431.231(c)(3).
    Note

    Hearing Scheduling

    A hearing must be held within 40 days of the hearing request unless a different period is provided by law, agreed to by the parties, or extended because a contestant requests a continuance.

    • Contested case hearings also follow the Office of Administrative Hearings Rules, specifically Chapter 2 of the Uniform Rules for Contested Case Practice and Procedure.
    Note

    Representation Requirements

    An applicant, client, or provider may represent themselves. An applicant or client may also use a lawyer admitted to practice in Wyoming or an authorized representative; a provider may be represented by a Wyoming-admitted lawyer.

    • The contestant must notify the Department in writing if they intend to be represented at the hearing.
    • A non-lawyer authorized to represent an applicant or client may advocate and draft pleadings or other documents, but may not provide legal advice or services or represent anyone before Wyoming courts.
    • A provider that is a corporation, professional corporation, limited liability company, partnership, governmental entity, or other legal entity may appear and be represented by a lawyer admitted to practice in Wyoming.
    • The contestant is responsible for attorney fees and representation-related costs.
    The Department's Medicaid rules may specify exceptions to this chapter's applicability.