Hearings Division - Medicaid
The information on this page is for Medcaid hearings which follow a simplified procedure. If your case concerns any other type of administrative hearing, click here.
The Hearings Division provides a forum for an independent hearing before an administrative law judge when a dispute with a state agency involving a person's rights, duties or privileges cannot be resolved through informal procedures. The following simplified procedures are specific to Medicaid cases and follow the legislative rules set out for Medicaid appeals.
FILING A CONTESTED MEDICAID CASE
- If you wish to appeal the denial or modification of your Medicaid services, you must complete the Recipient Hearing Request Form which is included with your denial or modification notice from the Department of Health and Human Services. Return two copies of the completed Hearing Request Form to the Office of Administrative Hearings and one copy to the Department of Health and Human Services within 30 days of the date the notice was mailed to you. The address for the Office of Administrative Hearings and the Department of Health and Human Services is located at the top of the Recipient Hearing Request Form.
- Be sure that the reason for the appeal is listed correctly in the center portion of your Hearing Request Form.
- If you want someone to assist you with the appeal, please list that individual's name, address and telephone number in the box located in the center of the Hearing Request Form.
- You must sign your name, write the date you are completing the form and BE SURE YOUR TELEPHONE NUMBER IS LISTED CORRECTLY. It is your responsibility to be sure the Office of Administrative Hearings has the correct telephone number where you may be reached for a telephonic hearing of your appeal.
- If you wish to have an in-person hearing you must contact the Office of Administrative Hearings after receiving your Notice of Telephone Hearing for further instructions. In-person hearings are scheduled in Raleigh unless you indicate that coming to Raleigh would be a hardship for you. If a hearing in Raleigh is a hardship and an administrative law judge approves an in-person hearing near your home, the hearing will be held in Newton/Asheville, Charlotte, High Point, Fayetteville, Wilmington, Elizabeth City/Halifax, or New Bern.
MEDIATION/BEFORE THE MEDICAID HEARING
- When the Office of Administrative Hearings receives your hearing request, your case will be referred to a mediator to set up mediation for your case. Mediation is a voluntary opportunity for the parties to attempt to settle the case between themselves with the help of a neutral, third person and without the formality of the court. The mediator will contact you to set a time for the mediation. You may elect to participate in mediation or to decline.
- The mediation must take place within twenty-five (25) days after the case is received by the Office of Administrative Hearings. Work with the mediator to be sure this deadline is met.
- The mediation will most likely be held by telephone conference. The mediator will join the parties for discussion of a possible settlement.
- The mediator will file a report with the Office of Administrative Hearings and the Department of Health and Human Services. The report will confirm what occurred at mediation.
- If you do not reach a settlement of the case, your case will be heard by an administrative law judge.
- You will need to provide any documentation that supports your position. Make three copies of these materials and mail two copies to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714 (or fax 919-431-3100); and mail the third copy to Belinda Smith, Special Deputy Attorney General, North Carolina Department of Justice, 9001 Mail Service Center, Raleigh, North Carolina 27699-9001 (or fax 919-334-0138). If you fax, you must still mail the Office of Administrative Hearings the original and 1 copy. Provide documents at least 5 business days before the hearing and include the case number on all correspondence.
- If you want other individuals to testify for you, you will need to either have them in the room with you at the time of the hearing or obtain telephone numbers so they may be joined in the hearing by telephone.
- The testimony and/or documentation you present must show that the department made a mistake denying or modifying your Medicaid services.
- If your request concerns Medicaid benefits you have been receiving, the benefits you received prior to the appeal will continue while your case is moving through the appeal process if you timely filed the appeal. The prior benefits will continue until there is a final decision in your case.
THE MEDICAID HEARING
- An administrative law judge will conduct the hearing. The judge will call you at the number listed on the Hearing Request Form. The judge will confirm that you received notice of the case. Please be sure to accept the certified mail notice of hearing from the Office of Administrative Hearings. The judge will also ask if you have received copies of the Department of Health and Human Services exhibits. These exhibits will also be mailed to you from the Attorney General by certified mail.
- You and the assistant attorney general may make opening statements. This statement generally outlines the evidence you are about to present and your position concerning the case.
- An assistant attorney general will represent the department. Two or more witnesses from the department will also appear for the department.
- One department representative will discuss the department policy, located in the department manual concerning the type of Medicaid assistance. The assistant attorney general will ask the first questions. The judge is neutral in these hearings but may ask some questions of all witnesses to be sure that certain legal points are presented. You will be able to ask questions after the assistant attorney general and judge ask their questions.
- The other department representative will talk about the specifics of why your request was modified or denied.
- After the departmental witnesses testify, you and any other witnesses you select will testify. The judge will ask questions to be sure that legal points are covered and you will be given an opportunity to make a statement at the end of your testimony.
- The assistant attorney general will ask questions of you and your witnesses after the judge has finished.
- You and the assistant attorney general may make closing statements. This statement summarizes your position in the case.
AFTER THE MEDICAID HEARING
- The judge will take all the written information submitted by the parties and the testimony offered by the parties and their witnesses into consideration while making a decision in the case.
- The judge will write a decision either agreeing with the department or reversing the department's decision.
- This decision will be made within twenty days of the hearing. This is a Final Decision issued under the authority of N.C. Gen. Stat. § 150B-34.
- The parties will receive this decision by mail.
APPEAL OF A MEDICAID DECISION
A party may appeal a Final Decision within 30 days after being served with a written copy of the decision by filing a Petition for Judicial Review in Superior Court of Wake County or in the Superior Court of the county where the person appealing resides. The Petition for Judicial Review is filed in the Clerk of Superior Court's office, Civil Division.
FORMS FOR MEDICAID APPEALS OR MEDIATION ARE PROVIDED AT THE TOP OF THIS PAGE. IF YOU REQUIRE A NEW RECIPIENT HEARING REQUEST FORM, CONTACT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO OBTAIN A NEW FORM. IF YOU HAVE QUESTIONS CONCERNING THE APPEALS PROCESS OR REQUIRE SPECIAL ACCOMMODATIONS , CALL THE OFFICE OF ADMINISTRATIVE HEARINGS AT (919) 431-3000 FOR ASSISTANCE.
THE MATERIAL PRESENTED AT THIS WEB SITE IS PROVIDED TO THE PUBLIC FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED AS LEGAL ADVICE. NOTHING CONTAINED HEREIN SHALL BE CONSTRUED TO BIND THE PRESIDING ADMINISTRATIVE LAW JUDGE OR THE OFFICE OF ADMINISTRATIVE HEARINGS TO ANY PRACTICE DESCRIBED HEREIN.
The Medicaid appeals process is set forth in N.C. Gen. Stat. § 108A-70.9A & B (2011) as follows:
§ 108A‑70.9A. Appeals by Medicaid recipients.
(a) Definitions. – The following definitions apply in this Part, unless the context clearly requires otherwise.
(1) Adverse determination. – A determination by the Department to deny, terminate, suspend, or reduce a Medicaid service or an authorization for a Medicaid service.
(2) OAH. – The Office of Administrative Hearings.
(3) Recipient. – A recipient and the recipient's parent, guardian, or legal representative, unless otherwise specified.
(b) General Rule. – Notwithstanding any provision of State law or rules to the contrary, this section shall govern the process used by a Medicaid recipient to appeal an adverse determination made by the Department.
(c) Notice. – Except as otherwise provided by federal law or regulation, at least 10 days before the effective date of an adverse determination, the Department shall notify the recipient, and the provider, if applicable, in writing of the adverse determination and of the recipient's right to appeal the adverse determination. The Department shall not be required to notify a recipient's parent, guardian, or legal representative unless the recipient's parent, guardian, or legal representative has requested in writing to receive the notice. The notice shall be mailed on the date indicated on the notice as the date of the determination. The notice shall include:
(1) An identification of the recipient whose services are being affected by the adverse determination, including the recipient's full name and Medicaid identification number.
(2) An explanation of what service is being denied, terminated, suspended, or reduced and the reason for the determination.
(3) The specific regulation, statute, or medical policy that supports or requires the adverse determination.
(4) The effective date of the adverse determination.
(5) An explanation of the recipient's right to appeal the Department's adverse determination in an evidentiary hearing before an administrative law judge.
(6) An explanation of how the recipient can request a hearing and a statement that the recipient may represent himself or herself or use legal counsel, a relative, or other spokesperson.
(7) A statement that the recipient will continue to receive Medicaid services at the level provided on the day immediately preceding the Department's adverse determination or the amount requested by the recipient, whichever is less, if the recipient requests a hearing before the effective date of the adverse determination. The services shall continue until the hearing is completed and a final decision is rendered.
(8) The name and telephone number of a contact person at the Department to respond in a timely fashion to the recipient's questions.
(9) The telephone number by which the recipient may contact a Legal Aid/Legal Services office.
(10) The appeal request form described in subsection (e) of this section that the recipient may use to request a hearing.
(d) Appeals. – Except as provided by this section and G.S. 108A‑70.9B, a request for a hearing to appeal an adverse determination of the Department under this section is a contested case subject to the provisions of Article 3 of Chapter 150B of the General Statutes. The recipient shall request a hearing within 30 days of the mailing of the notice required by subsection (c) of this section by sending an appeal request form to OAH and the Department. Where a request for hearing concerns the reduction, modification, or termination of Medicaid services, including the failure to act upon a timely request for reauthorization with reasonable promptness, upon the receipt of a timely appeal, the Department shall reinstate the services to the level or manner prior to action by the Department as permitted by federal law or regulation. The Department shall immediately forward a copy of the notice to OAH electronically. The information contained in the notice is confidential unless the recipient appeals. OAH may dispose of the records after one year. The Department may not influence, limit, or interfere with the recipient's decision to request a hearing.
(e) Appeal Request Form. – Along with the notice required by subsection (c) of this section, the Department shall also provide the recipient with an appeal request form which shall be no more than one side of one page. The form shall include the following:
(1) A statement that in order to request an appeal, the recipient must send the form by mail or fax to the address or fax number listed on the form within 30 days of mailing of the notice.
(2) The recipient's name, address, telephone number, and Medicaid identification number.
(3) A preprinted statement that indicates that the recipient would like to appeal the specific adverse determination of which the recipient was notified in the notice.
(4) A statement informing the recipient that he or she may choose to be represented by a lawyer, a relative, a friend, or other spokesperson.
(5) A space for the recipient's signature and date.
(f) Final Decision. – After a hearing before an administrative law judge, the judge shall return the decision to the Department in accordance with G.S. 150B‑37. The Department shall notify the recipient of the final decision and of the right to judicial review of the decision pursuant to Article 4 of Chapter 150B of the General Statutes. (2010‑31, s. 10.30(a); 2011‑398, s. 32.)
§ 108A‑70.9B. Contested Medicaid cases.
(a) Application. – This section applies only to contested Medicaid cases commenced by Medicaid recipients under G.S. 108A‑70.9A. Except as otherwise provided by G.S. 108A‑70.9A and this section governing time lines and procedural steps, a contested Medicaid case commenced by a Medicaid recipient is subject to the provisions of Article 3 of Chapter 150B of the General Statutes. To the extent any provision in this section or G.S. 108A‑70.9A conflicts with another provision in Article 3 of Chapter 150B of the General Statutes, this section and G.S. 108A‑70.9A control.
(b) Simple Procedures. – Notwithstanding any other provision of Article 3 of Chapter 150B of the General Statutes, the chief administrative law judge may limit and simplify the procedures that apply to a contested Medicaid case involving a Medicaid recipient in order to complete the case as quickly as possible.
(1) To the extent possible, OAH shall schedule and hear contested Medicaid cases within 55 days of submission of a request for appeal.
(2) Hearings shall be conducted telephonically or by video technology with all parties, however the recipient may request that the hearing be conducted in person before the administrative law judge. An in‑person hearing shall be conducted in Wake County, however, for good cause shown, the in‑person hearing may be conducted in the county of residence of the recipient or a nearby county. Good cause shall include, but is not limited to, the recipient's impairments limiting travel or the unavailability of the recipient's treating professional witnesses. The Department shall provide written notice to the recipient of the use of telephonic hearings, hearings by video conference, and in‑person hearings before the administrative law judge, and how to request a hearing in the recipient's county of residence.
(3) The simplified procedure may include requiring that all prehearing motions be considered and ruled on by the administrative law judge in the course of the hearing of the case on the merits. An administrative law judge assigned to a contested Medicaid case shall make reasonable efforts in a case involving a Medicaid recipient who is not represented by an attorney to assure a fair hearing and to maintain a complete record of the hearing.
(4) The administrative law judge may allow brief extensions of the time limits contained in this section for good cause and to ensure that the record is complete. Good cause includes delays resulting from untimely receipt of documentation needed to render a decision and other unavoidable and unforeseen circumstances. Continuances shall only be granted in accordance with rules adopted by OAH and shall not be granted on the day of the hearing, except for good cause shown. If a petitioner fails to make an appearance at a hearing that has been properly noticed via certified mail by OAH, OAH shall immediately dismiss the contested case, unless the recipient moves to show good cause within three business days of the date of dismissal.
(5) The notice of hearing provided by OAH to the recipient shall include the following information:
a. The recipient's right to examine at a reasonable time before the hearing and during the hearing the contents of the recipient's case file and documents to be used by the Department in the hearing before the administrative law judge.
b. The recipient's right to an interpreter during the appeals process.
c. Circumstances in which a medical assessment may be obtained at agency expense and be made part of the record. Qualifying circumstances include those in which (i) a hearing involves medical issues, such as a diagnosis, an examining physician's report, or a medical review team's decision; and (ii) the administrative law judge considers it necessary to have a medical assessment other than that performed by the individual involved in making the original decision.
(c) Mediation. – Upon receipt of an appeal request form as provided by G.S. 108A‑70.9A(e) or other clear request for a hearing by a Medicaid recipient, OAH shall immediately notify the Mediation Network of North Carolina, which shall contact the recipient within five days to offer mediation in an attempt to resolve the dispute. If mediation is accepted, the mediation must be completed within 25 days of submission of the request for appeal. Upon completion of the mediation, the mediator shall inform OAH and the Department within 24 hours of the resolution by facsimile or electronic messaging. If the parties have resolved matters in the mediation, OAH shall dismiss the case. OAH shall not conduct a hearing of any contested Medicaid case until it has received notice from the mediator assigned that either: (i) the mediation was unsuccessful, or (ii) the petitioner has rejected the offer of mediation, or (iii) the petitioner has failed to appear at a scheduled mediation. Nothing in this subsection shall restrict the right to a contested case hearing.
(d) Burden of Proof. – The recipient has the burden of proof to show entitlement to a requested benefit or the propriety of requested agency action when the agency has denied the benefit or refused to take the particular action. The agency has the burden of proof when the appeal is from an agency determination to impose a penalty or to reduce, terminate, or suspend a previously granted benefit. The party with the burden of proof on any issue has the burden of going forward, and the administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence.
(e) New Evidence. – The recipient shall be permitted to submit evidence regardless of whether obtained prior to or subsequent to the Department's actions and regardless of whether the Department had an opportunity to consider the evidence in making its adverse determination. When the evidence is received, at the request of the Department, the administrative law judge shall continue the hearing for a minimum of 15 days and a maximum of 30 days to allow for the Department's review of the evidence. Subsequent to review of the evidence, if the Department reverses its original decision, it shall immediately inform the administrative law judge.
(f) Issue for Hearing. – For each adverse determination, the hearing shall determine whether the Department substantially prejudiced the rights of the recipient and if the Department, based upon evidence at the hearing:
(1) Exceeded its authority or jurisdiction.
(2) Acted erroneously.
(3) Failed to use proper procedure.
(4) Acted arbitrarily or capriciously.
(5) Failed to act as required by law or rule.
(g) Decision. – The administrative law judge assigned to a contested Medicaid case shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision and send it to the parties in accordance with G.S. 150B‑37. (2010‑31, s. 10.30(a); 2011‑398, s. 33.)
NORTH CAROLINA ADMINISTRATIVE CODE
OFFICE OF ADMINISTRATIVE HEARINGS
SECTION .0100 - HEARING PROCEDURES
.0101 GENERAL (Paragraph (a) does not apply to Medicaid cases)
.0102 DEFINITIONS AND CONSTRUCTION (Item(3) does not apply to Medicaid cases)
.0103 COMMENCEMENT OF CONTESTED CASE: NOTICE AND FILING FEE (Paragraph (a) does not apply to Medicaid cases)
.0104 ORDER FOR PREHEARING STATEMENTS (This Rule does not apply to Medicaid cases)
.0105 DUTIES OF THE ADMINISTRATIVE LAW JUDGE
.0106 CONSENT ORDER: SETTLEMENT: STIPULATION
.0107 SETTLEMENT CONFERENCE (This Rule does not apply to Medicaid cases)
.0108 PREHEARING CONFERENCE (This Rule does not apply to Medicaid cases)
.0109 NOTICE OF HEARING (This Rule does not apply to Medicaid cases)
.0110 DISQUALIFICATION OF ADMINISTRATIVE LAW JUDGE
.0111 CONSOLIDATION OF CASES
.0112 DISCOVERY (Paragraphs (b),(c),(e),(f),(g) do not apply to Medicaid cases)
.0115 MOTIONS (This Rule does not apply to Medicaid cases)
.0117 INTERVENTION (This Rule does not apply to Medicaid cases)
.0118 CONTINUANCES (This Rule does not apply to Medicaid cases)
.0119 SECURE LEAVE PERIODS FOR ATTORNEYS
.0120 RIGHTS AND RESPONSIBILITIES OF PARTIES (Paragraph (e) does not apply to Medicaid cases)
.0123 OFFICIAL RECORD (This Rule does not apply to Medicaid cases)
.0124 VENUE (This Rule does not apply to Medicaid cases)
.0125 CONDUCT OF HEARING (This Rule does not apply to Medicaid cases)
.0126 REPEALED - HEARING OFFICER'S PROPOSAL FOR DECISION: EXCEPTIONS
.0127 ADMINISTRATIVE LAW JUDGE'S DECISION (Paragraph (a) does not apply to Medicaid cases)
.0128 EX PARTE COMMUNICATIONS
.0129 RECONSIDERATION OR REHEARING
.0130 AVAILABILITY OF COPIES
.0131 FINAL DECISIONS IN CONTESTED CASES
SECTION .0200 - MEDIATION SETTLEMENT CONFERENCE
This section and all the rules within this section (.0201 - .0208) do not apply to Medicaid cases.
.0201 ORDER FOR MEDIATED SETTLEMENT CONFERENCE
.0202 SELECTION OF MEDIATOR
.0203 MEDIATION SETTLEMENT CONFERENCE
.0204 DUTIES OF PARTIES, REPRESENTATIVES, AND ATTORNEYS
.0205 SANCTIONS FOR FAILURE TO ATTEND
.0206 AUTHORITY AND DUTIES OF MEDIATOR
.0207 COMPENSATION OF THE MEDIATOR
SECTION .0300 - EXPEDITED HEARING PROCEDURES FOR COMPLEX CONTESTED CASES
This section and all the rules within this section (.0301 - .0305) do not apply to Medicaid cases.
.0301 REPEALED - ORDER DESIGNATING COMPLEX CONTESTED CASES
.0302 REPEALED - FACTORS TO BE CONSIDERED
.0303 REPEALED - VENUE
.0304 REPEALED - EXPEDITED HEARING PROCEDURES FOR COMPLEX CONTESTED CASES
.0305 REPEALED - RULES AND PROCEDURES
SECTION .0400 - SIMPLIFIED PROCEDURES FOR MEDICAID APPLICANT AND RECIPIENT APPEALS