PI – Guidelines for Preparation and Management of Provider

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

Preparation and Management of Provider Appeals Related to FWA Page 1 of 10

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PI – Guidelines for Preparation and Management of Provider

Appeals Related to Fraud, Waste, and Abuse

Purpose:

1. Describe the preparation and management of cases entering the provider appeal

process.

2. Ensure all provider appeals are handled in accordance with Code of Federal

Regulations, Iowa Administrative Code, Iowa Code, and Medicaid policy. When

a recoupment is identified, a findings letter is sent to the provider. The provider

may appeal the findings in writing within 90 calendar days from the date of the

findings letter.

3. Individuals involved in the case (e.g., appellant(s), recipient(s), provider(s),

appellant(s) legal team or other parties participating in the appeal on behalf of

the appellant) are prohibited from having (ex parte) communication about the

appeal with the ALJ or any Iowa Medicaid Directors during the appeal process.

4. Providers are instructed in the PI findings letter to direct their appeal to the

Iowa Department of Health and Human Services (HHS); although, it is acceptable

for appeals to be sent informally via email or telephone call, which are then

forwarded to the Iowa Department of Health and Human Services.

5. All provider appeals approved by the Iowa Department of Health and Human

Services are certified and sent to the Department of Inspection and Appeals

(DIA) for the ALJ to set a Prehearing Conference date. If the request for an

appeal is not granted, the DIA sends a letter stating why the appeal was denied.

Identification of Roles:

RACI Definitions

RACI

RACI c

harts are a type of responsibility assignment matrices in project management. These

simple spreadsheets or tables highlight the different states of responsibility a stakeholder has over a

particular task or deliverable and denotes it with the lett

ers R, A,

C, or I.

(R)

Responsible

(A)

Accountable

(C)

Consulted

(I)

Informed

Iowa Medicaid PI Investigator – Responsible for preparation and management of

provider appeals related to their assigned cases on which an appeal is requested. (R)

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

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Iowa Medicaid Medical Necessity Review Manager – Supports appeals on cases where

clinical review decisions were made by a nurse investigator. (A)

Iowa Medicaid PI Audits & Investigations Manager – Liaison between State and AAG and

provides support as needed throughout the appeals process. (A)

Iowa Medicaid PI Director – Provides direction regarding whether to appeal an ALJ

Proposed Decision to the Director. (C)

Administrative Law Judge (ALJ) – Presides over the hearing process and issues a

Proposed Decision to the Iowa Department of Health and Human Services Director

(C)

Iowa Department of Health and Human Services Director– Performs Director review of

ALJ Proposed Decision if requested and renders a Final Decision. (C)

Assistant Attorney General (AAG) Office of the Attorney General of Iowa – Is informed

if a provider has legal representation or obtains legal representation at any time

throughout the appeal process. AAG provides legal counsel support or may assume

primary responsibility for an appeal where the provider obtains legal representation. (I)

Performance Standards:

Prepare documents and assist in appeal hearings for all PI cases where an appeal is

requested by a provider.

Path of Business Procedure:

1) Preparation and Management of Provider Appeals (Refer to the Appeal desk

guide):

 The Iowa Medicaid PI Investigator documents whether the provider has

indicated the involvement of legal counsel and notifies their manager. If the

provider has obtained legal counsel, the Iowa Medicaid PI Investigator or

their manager notifies the AAG and requests support in the appeal process.

 If the AAG assumes primary responsibility for a case, the Iowa Medicaid PI

Investigator should not directly communicate with the provider or the legal

representative, unless instructed otherwise. All inquiries should be referred

to the AAG. The AAG may interject himself or herself into the process at

any time if she or he determines to be appropriate.

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

Preparation and Management of Provider Appeals Related to FWA Page 3 of 10

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 If legal counsel for the appellant becomes involved at any time during the

appeal process, the assigned Iowa Medicaid PI Investigator or their manager

notify the AAG and proceed as instructed by the AAG. The instructions of

the AAG preclude any differing instructions contained in this process

document.

 The Iowa Medicaid PI Investigator or their manager must communicate

regularly with the AAG regarding open cases for which the AAG has

assumed responsibility and must include the AAG in any and all activities

and/or communications related to these cases in a timely manner (same

business day, when possible). If the AAG has not assumed responsibility for

an appeal, the Iowa Medicaid PI Investigator or their manager should

communicate with the AAG as needed for assistance, instruction, and

support during the appeal process.

2) Receipt of Provider Appeal

 When a provider appeal certification (Notice of Hearing) is received by the

Iowa Medicaid PI Unit, the Iowa Medicaid PI Investigator saves an electronic

copy of the original request. A copy of all the documentation relating to

each specific appeal will have a separate designated folder within the case file

created by the Iowa Medicaid PI Investigator.

 The Iowa Medicaid PI Investigator scans a copy of the appeal certification

into OnBase. The appeal certification then becomes a permanent part of the

OnBase provider file. The Iowa Medicaid PI Investigator also places a copy of

the appeal certification in the appeal folder within the case file.

 The Iowa Medicaid PI Investigator or a designee enters the appeal

information into the Appeals Log and is responsible for updating this log as

information becomes available. Information includes:

▪ Provider Name and Number

▪ Project ID

▪ Administrative Law Judge assigned to the case

▪ Appeal Number

▪ Recoupment amount

▪ Iowa Medicaid PI Investigator ’s Name

▪ Status of the case-dates and times along with descriptions, e.g., Certified

02/19/04

▪ Known Legal Representation

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

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3) Receipt of Notice of Prehearing Conference and Requesting a Prehearing

Conference

 The Iowa Medicaid PI Investigator may receive a Notice of Prehearing

Conference. At times, the appeal may be scheduled for appeal Hearing

without a Prehearing Conference. In that case, the Iowa Medicaid PI

Investigator should determine whether a Prehearing Conference is needed.

If so, as soon as possible, the request for Prehearing Conference along with

the reason for the request should be filed (with the assigned ALJ) and a copy

of the request should be sent to the appealing provider by the Iowa Medicaid

PI Investigator.

 The Iowa Medicaid PI Investigator reserves a conference room for the

scheduled date and time of the Prehearing Conference and sends a calendar

appointment with the date of the Prehearing Conference, including the

assigned conference room, via email to:

▪ AAG if involved in the case,

▪ Iowa Medicaid PI Investigator and their manager,

▪ The Iowa Medicaid PI Unit or Policy staff who may also be involved in the

case. (Additional information regarding the appeal may be sent with the

calendar appointment or in subsequent e-mails.)

 The Iowa Medicaid PI Investigator scans a copy of the Notice of Prehearing

and/or Hearing into OnBase.

▪ The Iowa Medicaid PI Investigator updates the appeal information into

the iSight database.

▪ The Iowa Medicaid PI Investigator will send a copy of the Findings Letter

(Notice of Determination – NOD) to the appointed Administrative Law

Judge (ALJ) and/or upload it into the Appeals Information System (AIS).

▪ The Iowa Medicaid PI Investigator continues updating the iSight database,

as new appeal information is provided.

4) Preparing for the Prehearing Conference

 The Prehearing Conference Notice may require the parties to prepare for

the Prehearing Conference and may set deadlines for preparation. The Iowa

Medicaid PI Investigator must follow all of the requirements and deadlines in

that Prehearing Conference Notice. Any of the preparations identified

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

Preparation and Management of Provider Appeals Related to FWA Page 5 of 10

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below may be replaced or supplemented by any requirements and deadlines

in the Prehearing Conference Notice.

 Generally, the Prehearing Conference Notice will require that one week

before the Prehearing Conference, the parties file a jointly compiled list or

table containing the information required by the Prehearing Conference

Notice. Therefore, the Iowa Medicaid PI Investigator must confer with the

Appellant to prepare such a list. If the Appellant is unavailable or

uncooperative, the Iowa Medicaid PI Investigator may file a proposed list or

table. The Iowa Medicaid PI Investigator must make that information

available to the Appellant before the Hearing.

 The Iowa Medicaid PI Investigator is to be prepared to identify and provide

the following information at the Prehearing Conference.

▪ Names of the individuals the parties intend to call as witnesses.

▪ General kinds of documents the parties intend to introduce as exhibits.

▪ Anticipated length of the Hearing.

▪ Whether an in-person or telephone Hearing is desired.

▪ Other procedural matters the parties may raise.

▪ Available dates and times for future Hearing related activities.

 Generally, by close of business on the day before the Prehearing Conference,

the Iowa Medicaid PI Investigator emails the ALJ and the Appellant with the

names and telephone numbers of all persons they wish to have participation

in the Prehearing Conference.

5) The Prehearing Conference

 The Iowa Medicaid PI Investigator or their manager will take their calendar

schedule to the Prehearing Conference to ensure that future appointments

can be made without conflicting with other scheduled events. All persons

who will participate in the Formal Hearing should be present or should make

their calendars available to the Iowa Medicaid PI Investigator before the

Prehearing Conference.

 To participate in the Prehearing Conference, the attendees should call into

the toll-free number indicated in the Prehearing Conference Notice at the

time indicated. Generally, the Iowa Medicaid PI Investigator and their

manager will be present. The Iowa Medicaid PI Account Manager may attend

as available or as needed. If legal counsel is involved, the AAG will attend.

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

Preparation and Management of Provider Appeals Related to FWA Page 6 of 10

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Additionally, other Iowa Medicaid PI Investigators or Clinical Nurse

Reviewers may attend.

 At the Prehearing Conference, the Iowa Medicaid PI Investigator or their

manager may object to the presence of anyone other than the appellant or a

representative of the appellant.

 If an attorney is unexpectedly present on behalf of the appellant, ask for a

continuance to have opportunity to get the AAG involved. If the request is

denied, proceed with the Prehearing Conference, and notify the AAG Iowa

immediately following the Prehearing Conference.

 If the appellant does not show up, move to dismiss the appeal as abandoned

under 441 I.A.C. 7.8(9).

 At the Prehearing Conference, the Iowa Medicaid PI Investigator will identify

and provide the following information:

▪ Identification of the issues.

▪ Names of the individuals the parties intend to call as witnesses.

▪ General kinds of documents the parties intend to introduce as exhibits.

▪ Anticipated length of the hearing.

▪ Whether an in-person or telephone hearing is desired.

▪ Other procedural matters the parties may raise.

▪ Available dates and times for future hearing related activities

 At the end of the Prehearing Conference, the Iowa Medicaid PI Investigator

updates the appeals log and iSight database.

 The Iowa Medicaid PI Investigator reserves a conference room, if needed, for

the hearing and notifies the appropriate parties.

6) Preparing for Formal Hearing

 The Iowa Medicaid PI Investigator develops a reminder of dates that required

exhibits or other documents are due to the ALJ or appellant. The Iowa

Medicaid PI Investigator will complete tasks within the timelines below unless

the Prehearing Conference or Hearing Notice assigns different deadlines.

 The Iowa Medicaid PI Investigator prepares a complete exhibit package with

each exhibit clearly labeled. An index or table of contents is prepared to

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

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detail the list of exhibits. Each item that might be used in the appeal must be

included in the exhibit.

 At least two weeks before the hearing, the parties exchange the exhibits they

plan to offer at the hearing. Exhibits are marked at the bottom of the page.

Generally, the notices require HHS to mark its exhibits numerically from 1-

100 in sequence (e.g., Exhibit 1, Exhibit 2, Exhibit 3, etc.). All pages of the

exhibits must be numbered.

 The Iowa Medicaid PI Investigator prepares the exhibit books, CDs or

electronic copies to be sent. Four copies are made of all documents

requested. One for the Iowa Medicaid PI Investigator, one for the ALJ

(and/or uploaded into the AIS), one for the provider/appellant and one for

the legal counsel (if represented).

 Each letter and/or fax document related to appeals, as with regular review

projects, must contain an Outgoing Correspondence Tracking Log Number,

so that the documents are tracked appropriately.

▪ At least two weeks before the hearing (or earlier as directed by the ALJ),

the Iowa Medicaid PI Investigator sends the ALJ one complete copy of the

exhibits and/or uploads it into the AIS, as well as sending a list of

witnesses the Department will call.

▪ The Iowa Medicaid PI Investigator must ensure that the ALJ does not

receive exhibits or case information before the appellant or material

different than was provided to the appellant.

▪ The exhibits to the ALJ are provided in well-organized and labeled

format.

▪ All written materials compiled by the PI Unit undergo the Quality

Assurance process.

7) The Formal Appeal

 General progression: Preliminary Matters; Opening Statements; Offer

Exhibits into Evidence; Iowa Medicaid’s Case; Petitioner’s Case; Iowa

Medicaid Rebuttal Case if needed; Closing Arguments.

 If the Petitioner or a representative for Petitioner do not show up, move for

default under 441 I.A.C. 7.13(4).

 Make sure only parties, representatives, and witnesses are present. Ask

Judge to exclude any others.

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

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 The parties may be allowed to offer exhibits not exchanged before the

hearing at the discretion of the ALJ. If allowed, exhibits not previously

exchanged must be provided to the ALJ and the appellant per the ALJ’s

instructions.

8) After the Formal Hearing

 After the formal hearing, the ALJ will issue a Proposed Decision to the Iowa

Department of Health and Human Services Director (“Director”). The Iowa

Medicaid PI Investigator must notify the Iowa Medicaid PI Investigator or

designee in writing within two business days of the PI Unit’s receipt of the

Proposed Decision of the ALJ.

 If neither party requests Director Review, the Proposed Decision becomes

the ALJ’s Final Decision.

9) After the Formal Appeal – Director Review

 Both parties have 10 days following the issuance of the Proposed Decision to

request Review by the DHHS Director.

 Following the issuance of the Proposed Decision by the ALJ, Iowa Medicaid

PI Investigator and their manager will review the Proposed Decision to

evaluate whether it is acceptable.

 If the ruling is not considered acceptable, the Iowa Medicaid PI Audits &

Investigations Manager or designee will consult the AAG and Iowa Medicaid

PI Director to determine whether to appeal the Proposed Decision to the

Director.

 If an appeal is approved, the Iowa Medicaid PI Audits & Investigations

Manager or designee will draft a letter requesting the Director to review and

reverse or amend the Proposed Decision. This letter will be given to the

designated Policy person who will present it to the Appeals Advisory

Committee. It must be dated and delivered within 10 days of the date of the

ALJ’s Proposed Decision.

 The Request for Review of Proposed Decision must explain why the ruling is

deficient and how the legal and supplementary references were not followed.

 If the Director grants a Review of the Proposed Decision, either party may

request oral argument, but the Director has the discretion to grant or deny

oral argument.

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

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 After Review, the Director must issue a Final Decision within 90 days from

the date of the Request for Review. However, that time-frame may be

extended for essential reasons by up to an additional 30 days when approved

by the Administrative Law Judge.

 If the Final Decision of the Director does not fully affirm the PI findings,

within seven days of receipt of the Final Decision, the Iowa Medicaid PI

Investigator sends a revised findings letter and explanatory spreadsheet to

the provider with a copy to the ALJ. Corrective payments due must be

made within seven days and should be retroactive to the date of the

incorrect action.

10) Provider Appeal of Final Decision

 If the provider does not agree with the Director’s Final Decision, the

provider may appeal the case to the judicial system. The appeal must be

made within 30 days of the Final Decision of the ALJ. If the PI Unit receives

an appeal, the AAG should be notified immediately.

11) Closing the File

 The Iowa Medicaid PI Investigator updates the case on the Appeals Log and

moves the case to the Sr. Financial Analyst to collect payment or closes the

case if the identified balance has been paid in full.

 Refer to “Conducting a Full Review” standard operating procedure to follow

review process through to closure. (Also refer to all i-Sight desk guides for

database documentation guidelines.)

Forms/Reports:

Appeals Tracking Log

Appeal Notification to the ALJ

Appeal Notification to the Provider

Final Decision Second Notice Payment Past Due Letter

FOR – Final affirmed Decision by ALJ or Director with Recoupment

Modified Final Decision by ALJ – Revised Recoupment

Prehearing Requirements ALJ

Referral for Review of Proposed Decision (Director Review)

DHS Staff Submitting Request for Director Review

Interfaces:

Iowa Department of Health and Human Services

Iowa Medicaid Enterprise

Program Integrity Unit

________________________________________________________________________

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Appeals Information System (AIS)

Department of Health and Human Services (DHHS)

Department of Inspection and Appeals (DIA)

Assistant Attorney General (AAG)-Iowa Medicaid

Attachments:

Appeals Tracking Log:

\\dhsime\PI\PI Appeals Log\PI Appeals Tracking Log_2016-CURRENT.xlsx

Appeals templates:

Appeal Notification

to the ALJ - 18_v.2.dotx

Appeal Notification

to the Provider - 18_v.2.dotx

Final Decision -

Second Notice Payment Past Due - 18_v.2.dotx

FOR - Final

Affirmed Decision by ALJ or Director with Recoupment - 18_v.2.docx

Modified Final

Decision by ALJ - Revised Recoupment - 18_v.2.dotx

Prehearing

Requirements ALJ - 18_v.2.dotx

Referral for Review

of Proposed Decision.docx

DHS Staff Submitting

Request for Director Review (1).docx

Desk Guide for Appeals

Desk Guide for

Appeals_FINAL10.14.2020.docx