This is meant to provide a basic guide about appeal hearings. It includes how to prepare, the process, items to be submitted as exhibits, how the hearing is conducted and what to expect.
Preparation
- Preparation begins at the Initial Assessment Home Visit. The explanation of the (MCCY or MCAW) Program should include clarification that authorized services are based on medical necessity. As the participant’s condition improves the participant/responsible party should expect that the amount of services will be decreased.
- Document the facts of the information obtained at every visit and every contact. All documentation in MOHSAIC and other tools must reflect the facts that have been obtained and support the determination of medical necessity for the services you have authorized. In the case of appeals the documentation must support the determination for the reduction/discontinuation of services
- The participant/responsible party has the right to appeal any denial, reduction or change in services.
- Authorize the service/amount of services determined to be medically necessary. When the assessment indicates the need to decrease or change services, make the WHOLE change. Do not attempt to “wean” the services away. EXAMPLE: A client is getting 20 hours a day of PDN and the assessment indicates that they only need 4 hours a day of PDN. Decrease the authorized hours to 4 hours a day. Do not reduce the hours to 10 a day for 3 months until the next home visit.
- Appeal hearings are based only on the authorization being appealed. If you do an assessment in January and the family appeals, the appeal decision only applies to that authorization period. When you do an assessment in April, if it is different from the January assessment it could be appealed too. If you do not make any changes in April, there is nothing to appeal.
Process
- When the service coordinator makes the determination to deny, reduce or change services, a “right to appeal” letter is sent to the family. This applies to any denial or change, even if the family agrees with it.
- BSHCN and/or the MCCY & MCAW Program Manager will be notified when a family appeals a decision BSHCN staff has made.
- The family will receive a letter from the MO HealthNet Division telling them the date and time of the appeal hearing.
- Normally the appeal hearings are held by telephone. BSHCN provides the names of those testifying and their phone numbers to DSS/MO HealthNet Division.
- The hearing is typically conducted by conference call but the family can request a face-to-face hearing. If they do request a face-to-face hearing, it will be held at the DFS office nearest to the family. The Hearing Officer will be present in person with them. The Service Coordinator, Regional Coordinator, MCCY & MCAW Program Manager and a representative from DSS/MO HealthNet Division will attend by conference call.
- BSHCN will be asked to submit exhibits that defend the decisions it made. Items to include are:
- The CSR that applies to either PDN or Personal Care (whichever is being appealed)
- Section 13 of the appropriate MO HealthNet Provider Manual
- The PDN or PCA assessment tool with instructions
- The Private Duty Nursing Acceptance form (reference to MO HealthNet Provider Manual)
- The MCCY/MCAW monitoring log with the guideline (if applicable)
- Progress notes that support the decision, screen printed from MOHSAIC
- Copies of Provider Nursing Notes or PCA notes (optional)
- A copy of the letter that notified the participant/responsible party of appeal rights.
- In addition to the above documents, DSS/MO HealthNet Division will provide their response to the letter containing the appeal rights and the rules for the MO HealthNet appeals process.
The Hearing
- The Hearing officer will call everyone that is to participate.
- Everything is recorded.
- The Hearing officer will read a statement.
- Everyone present for the hearing (by phone or in person) will be sworn in by the Hearing Officer.
- The Hearing Officer will ask DSS/MO HealthNet Division to present their exhibits
- The MCCY & MCAW Program Manager, Service Coordinator and others designated as witnesses from BSHCN will be asked to present our exhibits
- Present an exhibit, explain what it is and point out what section is being submitted as evidence.
- Keep explanations as short as possible but do not omit important information for the sake of time.
- The participant/responsible party will be given an opportunity to ask questions after each exhibit has been presented before the hearing officer accepts the exhibit into evidence.
- The family will be asked to present their testimony/exhibits.
- The hearing will be closed.
The Hearing Officer may give the participant/responsible party additional time to submit exhibits for review by the hearing officer (usually a week).
BSHCN will be notified of the decision by DSS/MO HealthNet Division.