TO AMEND THE MEDICAID FAIRNESS ACT; TO MODIFY THE DEFINITION OF "ADVERSE DECISION" UNDER THE MEDICAID FAIRNESS ACT; AND TO PROVIDE FOR ADMINISTRATIVE RECONSIDERATION UNDER THE MEDICAID FAIRNESS ACT.

Stronger appeal rights for Medicaid providers

Arkansas expands which harmful Medicaid decisions qualify for review, including decisions by state reviewers and contractors. Covered decisions concern care levels, billing codes, medical need, prior approval, care reviews, care settings, audits, and inspections. They also include provider payment calculations and corrective action plans, even without a direct money loss. General payment-system design changes adopted through rulemaking are excluded. Providers can ask the Department of Human Services to reconsider or appeal directly to the Department of Health’s Office of Medicaid Provider Appeals. Providers can act for themselves, a recipient, or both; reconsideration is not required before appeal. Appeal rights must be read broadly, without undue technical or procedural barriers. A Department of Health administrative law judge hears appeals under Arkansas’s administrative procedure law, subject to this law’s exceptions. Multiple appeals from one provider can be combined. Individual and corporate providers can appear personally, through a corporate representative, or through a lawyer with advance notice. Recipients can attend hearings about their care, but their participation cannot be required for a provider’s appeal. The department can subpoena a recipient, but failure to appear does not stop the appeal.