South carolina department of health and human services medicaid policy and procedures manual

• 
  The request for a fair hearing must be made in writing and signed by the applicant/ beneficiary or his authorized representative.
  
• 
  The request must be made within 30 calendar days from the date on the Notice of Adverse Action. If the request is received after 30 days, the eligibility worker should still follow the steps listed below for an appeal, and include a request to dismiss the appeal for failing to meet the time frame. The hearing officer will decide if the appeal should continue (such as for good cause), or if it should be denied.
  
• 
  If the applicant/beneficiary calls to ask for an appeal, the eligibility worker should complete Part I of the DHHS Form 3260 ME, Request for Fair Hearing for Medicaid Applicant/Beneficiary, and then instruct the applicant/beneficiary to complete Part II, sign, date, and return it to the eligibility worker for submission to the DHHS Division of Appeals.
  
• 
  The written request for a hearing consists of the DHHS Form 3260 ME or a letter from the applicant/beneficiary stating his wish for a hearing and the reason(s) for requesting a hearing. Should the applicant/beneficiary request an appeal by letter, the Medicaid eligibility worker should complete Part I of the DHHS Form 3260 ME for submission to the DHHS Division of Appeals along with the letter. Note: If there is a signed appeal statement, no applicant/beneficiary signature is needed on the DHHS Form 3260 ME.
  
• 
  If by chance the applicant/beneficiary appeals directly to the Division of Appeals, the division will notify the eligibility worker to submit the DHHS Form 3260 ME and prepare an appeals summary. The eligibility worker will submit the DHHS Form 3260 ME for all appeals, even if the client decides to submit the DHHS Form 3260 ME to the DHHS Division of Appeals.
  
• 
  If the request for a hearing is based on a disability decision, the eligibility worker will submit the disability decision (copy of Form MAO99- Medicaid Disability Determination), along with the hearing request.
  

• 
  The supervisor or his designee must:
  
  • 
    Review the case action for accuracy
    
• 
  If it is determined that the DHHS decision was made in error, the worker must complete the following actions:
  
  • 
    Complete at “letter of correction” which must contain information advising the beneficiary that:
    
    • 
      An error was made
      
    • 
      The error has been corrected
      
    • 
      Their eligibility is continued if the error resulted in a closure.
      
  • 
    Complete any needed manual notices and mark them Corrected Copy (Example: Corrected DHHS Form 3229, A Cost of Care Notice)
    
  • 
    Submit the following to the Division of Appeals, sending a copy to the applicant/beneficiary/authorized representative (if applicable), and retaining a copy for the case file:
    
    • 
      DHHS Form 3260
      
    • 
      “Letter of correction”
      
    • 
      Any manual notices reflecting a correction
      

• 
  Petitioner’s name, address, phone number;
  
• 
  Category of Assistance;
  
• 
  Medicaid Beneficiary ID (s) and Household Number;
  
• 
  Date application or review was stamped as received by DHHS;
  
• 
  Date (s) of action (denial, closure, re-budget, etc…);
  
• 
  A statement of the eligibility criteria that were met;
  
• 
  Reason(s) for the Notice of Adverse Action (include all criteria that were not met); and
  
• 
  Whether retroactive benefits were requested and the period;
  
• 
  Statement of other categories considered (Exparte Determination);
  
• 
  Name, address and phone number of person completing the appeal summary;
  
• 
  A copy of the DHHS Form 3315, Appeals Package Checklist.
  

• 
  Completed DHHS Form 3260
  
• 
  Appeals Summary
  
• 
  All supporting documents, to include:
  
  • 
    Application/review form if the beneficiary’s statement on the form was used as a basis for the action
    
  • 
    Income Verification, such as:
    
    • 
      Check stubs; wage statements; DHHS Form 1245 ME, Wage Verification
      
    • 
      Income Tax Returns
      
    • 
      Child support printouts or DHHS Form 1216 ME, Voluntary Child Support
      
    • 
      Social Security, VA, Unemployment Benefits
      
    • 
      IEVS printouts, award letters, DHHS Form 1212 ME, Veterans Information
      
  • 
    Resource Verifications, such as:
    
    • 
      Bank statements, DHHS Form 1253 ME, Financial Investigation
      
    • 
      Property verification, DHHS Form 1255 ME, Real and Personal Property
      
    • 
      Budget sheets
      
  • 
    Other documentation/verification, such as:
    
    • 
      Citizenship/alien verification
      
    • 
      Copies of MPPM sections supporting the case action
      

• 
  A beneficiary may receive a continuation of Medicaid benefits only if the request for a fair hearing is made in writing prior to the effective date of closure in MEDS (the first day of the month in which Medicaid eligibility ended). The eligibility worker must take the appropriate steps in MEDS to reopen the case.
  

• 
  The eligibility worker must explain to the beneficiary that if the hearing officer rules in support of the action or decision made by SCDHHS, any payments made to providers for services received by the beneficiary during this period are subject to repayment.
  

The beneficiary can decline the continuation of benefits on the DHHS Form 3260 or by other written request such as a letter or fax.

• 
  If the beneficiary declines in writing prior to the effective date in MEDS, do not reopen the case.
  
• 
  If the beneficiary declines in writing after the case has been reopened, the eligibility worker must immediately close the case using Reason Code 004.
  

• 
  If the request for a fair hearing is received on or after the date eligibility ends in MEDS, benefits cannot be continued.
  

• 
  If the hearing officer rules in support of the agency’s action or decision, the eligibility worker must prepare an overpayment summary in accordance with policy as outlined in MPPM 101.17.03.
  

• 
  Discuss the situation of the applicant/beneficiary,
  
• 
  Discuss the reasons for the proposed action, and
  
• 
  Provide an opportunity for the applicant/beneficiary to present information to show that the proposed action is incorrect.
  

Because of this conference, if it is indicated that the eligibility worker has committed an error, then the eligibility worker must take corrective action and notify the applicant/beneficiary and the DHHS Division of Appeals of the decision. This conference does not nullify the right to a hearing of the applicant/beneficiary.