MFAW Guidebook

Appeals

The participant, parent(s), and/or responsible party(ies)  shall have written notification of any agency action that adversely affects the request for, or amount of, authorized MFAW services. These agency actions include, but are not limited to, any change (i.e., decrease or closing of an MFAW service), denial of a request for change (i.e., increase or an additional MFAW service), or denial of an initial request for MFAW services. When a participant, parent(s), and/or responsible party(ies)  is in agreement with or requests a reduction, denial, or closing of MFAW services, this is not considered an adverse action but a notification letter will be sent.

The MFAW Program participant, parent(s), and/or responsible party(ies) have the right to request an appeal of a SHCN decision within 90 calendar days of the date of the notification letter by contacting the Department of Social Services (DSS) by telephone at (800) 392-2161, email at  MHD.PSURefferrals@dss.mo.gov , or by U.S. Postal Mail at:

Department of Social Services
MO HealthNet Division, Constituent Services Unit
P.O. Box 6500, Jefferson City, MO 65101-6500

If the participant, parent(s), and/or responsible party(ies) requests the hearing within 10 calendar days of the date of the notification letter, they may request services to continue at the current level until the hearing officer makes a decision. If the SHCN decision is upheld by the hearing officer, the State has the right to request payment from the participant, parent(s), and/or responsible party(ies) for the difference in services that were delivered during the appeal process.

When an appeal request is received, SHCN will be notified by the DSS. SHCN must immediately respond with a list of SHCN witnesses and dates of availability. Upon receiving the appeal notification, the SC, assisted by the RC and PM, will gather and submit supporting evidence for the decision made by SHCN to DSS/MO HealthNet Division. All relevant policies and SHCN specific documents from the case record used to support the decision for the adverse action shall include, but are not limited to:

• State statutes,
• Code of State Regulation (CSR),
• MO HealthNet guidelines, and
• SHCN documents used in the regular course of business.

Using the information that has been collected, the SC, in consultation with the RC and PM, creates a summary of the pertinent information and identifies the order of the exhibits to be presented at the hearing. The prepared packet is then provided to the PM to be submitted to the Hearing Officer along with a list of SHCN witnesses, contact information, and the exhibits each will present.

A legal hearing will be scheduled by DSS/MO HealthNet Division.  The participant/responsible party(ies) will be notified of the time and place of the hearing by DSS/MO HealthNet Division.  SHCN staff typically attends the hearing via conference call.  There may be variations in how each Hearing Office conducts the appeal hearing.  Below is an outline for the general process of an appeal hearing.

The Hearing Process

• The Hearing Officer will place a call to all parties involved including, but not limited to, the participant, parent(s), and/or responsible party(ies)  and their representatives, SC, RC, PM, MHN representative, and DHSS Office of General Counsel representative.
• The hearing is audio recorded.
• The Hearing Officer will read an introductory statement.
• Individuals 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 initiate the presentation of the agency’s case.
• The PM, RC, SC, and others designated as witnesses from SHCN will be asked to present exhibits as follows:
• Exhibits are presented in sequential order and one at a time.
• Identify each exhibit by explaining what it is (e.g., home visit progress note, PDN assessment, participant contact progress note, provider nursing notes, etc.) and how it relates to the case.
• Request that each exhibit be entered into the legal record.
• Keep explanations as short as possible but do not omit important information for the sake of time.
• The participant/responsible party(ies)  and/or their representatives will be asked to present their testimony/exhibits.
• The Hearing Officer may allow the participant, parent(s), and/or responsible party(ies) and/or their representative to ask additional questions of SHCN staff.
• The SHCN staff are allowed to respond but are not allowed to question or rebut the participant, parent(s), and/or responsible party(ies) and/or their representatives testimony.
• The hearing will be closed. The Hearing Officer may give the participant, parent(s), and/or responsible party(ies) additional time to submit exhibits for review by the Hearing Officer.

SHCN will be notified of the decision by DSS/MO HealthNet Division. SHCN will not change the authorization for services until the participant, parent(s), and/or responsible party(ies) have been formally notified of the hearing appeal outcome.

Complaints

All concerns or complaints should be immediately forwarded to the RC for resolution.  The RC will consult with the PM and Bureau management if necessary.