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PACE application processing activity will be monitored by DHB. On the date of disposition, complete and fax the DHB-5166, Pace Application Report, to (919) 224- 1070, Attention: Medicaid Eligibility Unit.

XIII. PACE SERVICES – INTERNAL APPEAL PROCESS

A. Appealing a denied PACE service

When a service is denied or not paid, there is an internal PACE appeal that can be requested by the beneficiary. This appeal is not a Medicaid appeal and the process takes place between the PACE Organization and the PACE beneficiary. Caseworkers should refer the beneficiary to the PACE Organization to request this type of appeal.

B. Appealing to Medicare or Medicaid

After the internal PACE appeals process is completed, if the PACE beneficiary is still not satisfied, an appeal to either Medicare or Medicaid may be requested. If the beneficiary is requesting a Medicaid appeal, the PACE Organization should use the DHB-5165, PACE Referral Request for a Medicaid Hearing, as a means of communicating the request to the local agency. The date of the appeal request is the date that the DHB-5165 is received by the local agency.

XIV. MEDICAID APPEAL PROCESS

A. Appeal requirements apply to PACE cases just as with any other Medicaid case.

B. Refer to MA-2420, Notice and Hearings Process.