Page 24

Title 8: Medicaid Page 22 Iowa Department of Health and Human Services Employees’ Manual Chapter A: Administration Appeals Revised January 13, 2023

Appeals Legal reference: 42 CFR 431.200, 431.220, 441 IAC 7.5(17A) The client has a right to appeal any decision and to request an appeal hearing. No one may limit or interfere with this right. Examples of adverse actions in which a hearing may be granted include: ▪ The denial of medical assistance. ▪ The delay in acting on the client’s application with reasonable promptness. ▪ The suspension, reduction, or termination of medical assistance. ▪ The decision regarding attribution of resources. See 1-E, Appeals and Hearings, for a complete explanation of the Department’s appeal process, including worker and client responsibilities, time limits, and appeal decisions. If a person gains eligibility after an appeal decision, providers can submit claims for covered services that have not been paid to the IME. If the date the service was rendered is more than 365 days before eligibility was established, the provider must attach to the original claim form a statement from the IM worker that: ▪ Indicates the date on which the Department was notified of the eligibility determination and ▪ Lists the retroactive months. Prepare the statement and explain to the client what instructions to give to providers in this situation. Providers must submit claims within 365 days after the eligibility determination. The following sections address: ▪ When paid bills can be reimbursed after the appeal decision. ▪ Bills that cannot be reimbursed. ▪ The reimbursement process. Reimbursement After Appeal Decisions Legal reference: 441 IAC 75 (Rules in Process) Members and county agencies can receive direct reimbursement for certain paid medical bills. When an appeal decision by the Department or the Social Security Administration on an eligibility issue favors the member, members and county relief agencies are entitled to reimbursements if all of the following conditions apply: ▪ The medical bills were for services covered by Medicaid. The Iowa Medicaid Enterprise (IME) determines whether the medical bills are covered and the Medicaid rate. ▪ The medical bills were actually paid in the appeal period (the time between the date of denial of the initial application and the issuance of the Notice of Decision or Notice of Action that approves Medicaid).