Appeals and Grievances

The DHHS Hearing Office:

  • Conducts impartial informal appeals (reconsideration reviews) regarding adverse determinations (e.g., recoupment amounts accessed after post-payment reviews or Medicaid provider denial or enrollment termination) made by Medical Assistance or one of its agents or contractors
  • Hears appeals by long-term care residents who are being transferred or discharged from an adult care home or skilled nursing facility and for individuals who appeal a Preadmission Screening and Resident Review (PASRR) determination.
  • Has the authority to conduct external second level reviews for Health Choice recipients who have a denial, reduction, suspension or termination of health services.

Skilled Nursing Facility Discharge Appeals

The Hearings Office conducts formal hearings for residents appealing a notice of discharge from a Skilled Nursing Facility. (10A NCAC 22H.0200)

Adult Care Home Discharge Appeals

The Hearing Office conducts formal hearings for residents appealing a notice of discharge from an Adult Care Home. (NCGS § 131D-4.8 and 10A NCAC 13F.0702)

Transfer/Discharge Process Webinars

These webinars are for informational purposes only and are not to be considered legal advice. If you have questions of a legal nature after viewing these materials, you are encouraged to consult an attorney.

Please Note: Subsequent to the recording of these webinars the language of federal regulations concerning transfers and discharges from nursing homes has been refined and additional requirements added. In addition, these regulations have been moved from 42 CFR 483.12 to 42 CFR 483.15(c). Please review this revised regulation to ensure full understanding and compliance. Thank you.

PASRR Adverse Determination Hearings

Hearing Office conducts formal hearings for adverse PASRR determinations. (10A NCAC 22H.0300)

PASRR is a federally mandated program for screening applicants and residents of Medicaid certified nursing facilities to ensure that individuals with serious mental illness, intellectual disabilities or conditions related to intellectual disabilities who are entering or residing in Medicaid-certified nursing facilities receive appropriate placement and services.

Continuance Requests. Requests for the continuance of a hearing will be granted at the discretion of the Hearing Officer if good cause is shown. “Good cause” is circumstances beyond the control of the party requesting the continuance.

Hearing continuance requests must be made in writing and must be received by the Hearing Officer assigned to the case at least 5 days prior to the scheduled hearing date. No continuances will be granted after that time except for extraordinary circumstances as determined by the Hearing Officer if good cause is shown. Parties should notify the opposing party when requesting a continuance.

Examples of good cause include but are not limited to:

  • Death or illness of a party, representative or attorney
  • Lack of proper notice of the hearing
  • Parties have agreed to enter into settlement negotiations and both sides request a continuance to pursue settlement
  • Attorney has a scheduling conflict with another court appearance that takes precedence
  • Party obtained legal counsel subsequent to filing the appeal and the attorney needs additional time to prepare for hearing

Contact

Yvonne K. Smith, JD
919-814-0090
Fax: 919-882-1179
Medicaid.Hearings@dhhs.nc.gov

https://medicaid.ncdhhs.gov/beneficiaries/appeals-and-grievances