Governor, Planning and Budget, Inspector General of Medicaid Services (Office of)

Rule R367-1

Office of Inspector General of Medicaid Services

Notice of Proposed Rule

(New Rule)

DAR File No.: 35879
Filed: 02/15/2012 10:50:07 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to implement the initial administrative rules for the Office.

Summary of the rule or change:

This rule contains the duties, practices, policies, and procedures for the Office of Inspector General (OIG).

State statutory or constitutional authorization for this rule:

• Title 63, Chapter 4

This rule or change incorporates by reference the following material:

• Adds 42 USC 139a(1)(3), published by Government Printing Office, 2011
• Adds 42 CFR 431.107(b)(2), published by Government Printing Office, 2011
• Adds 42 CFR 456 Subpart 6, published by Government Printing Office, 2011
• Adds 42 CFR 455.13, published by Government Printing Office, 2011
• Adds 42 CFR 431 Subpart E, published by Government Printing Office, 2011
• Adds 42 CFR 455.21, published by Government Printing Office, 2011
• Adds 42 CFR 1007, published by Government Printing Office, 2011

Anticipated cost or savings to:

the state budget:

The implementation of Rule R367-1 will not have any aggregate cost to the state budget. The rule further clarifies the duties and procedures of the Office of Inspector General outlined in Sections 63J-4a-101 through 63J-4a-602. No other expense is created by the issuance of this rule. There will be savings to the state budget, this rule will further assist the OIG to recoup and recovery misappropriated Medicaid funds. This amount will vary year to year based upon the results of the audits.

local governments:

The promulgation of this rule will not result in direct and measurable costs for local governments. Local governments are not involved in the Medicaid Program. Additionally, the OIG will be collecting wrongfully acquired Medicaid funds. These are funds that the local governments were not originally entitled to; any funds paid by the local government, if any, would be a reimbursement of state and federal money.

small businesses:

The promulgation of this rule will not result in direct and measurable costs for small businesses. The OIG will be collecting wrongfully acquired Medicaid funds from small and solo practice medical providers. These are funds that the providers were not originally entitled to; any monies paid by the providers to the OIG, if any, would be a reimbursement of state funds. Therefore, there would be no additional costs to small businesses, just a reimbursement to the state.

persons other than small businesses, businesses, or local governmental entities:

The promulgation of this rule will not result in direct and measurable costs for other entities. The OIG will be collecting wrongfully acquired Medicaid funds from hospitals, large provider groups, pharmacies. These are funds that the providers were not originally entitled to; any monies paid by the providers to the OIG, if any, would be a reimbursement of state funds. Therefore, there would be no additional costs to small businesses, just a reimbursement to the state.

Compliance costs for affected persons:

Rule R367-1 does not create new compliance costs for any local government or business. There are no regulatory mandates created by this rule. The rule establishes the OIG's duties, audit responsibilities, and administrative hearing processes. Due to this, there is no cost created by the implementation of this rule.

Comments by the department head on the fiscal impact the rule may have on businesses:

Rule R367-1 does not create any additional costs to local governments or any businesses. The rule will outline the daily operations of the OIG. The office will seek to recover recoupment of wrongfully or erroneously acquired Medicaid funds. The entities that inappropriately received the monies do not incur additional costs, other than a reimbursement to the state of the money they were not otherwise entitled to. Further, entities and providers that are assessed a recoupment may have this recoup offset by future payments. This will minimalize the impact to daily operations of the provider. The fiscal impact of Rule R367-1 follows the analysis conducted by the Office of Legislative Fiscal Analyst report for H.B. 84 (2011 General Session), which founded the office in July of 2011.

Ron Bigelow, Executive Director GOPB

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Governor
Planning and Budget, Inspector General of Medicaid Services (Office of)
288 N 1460 W
SALT LAKE CITY, UT 84116

Direct questions regarding this rule to:

• Michael Green at the above address, by phone at 801-538-6123, by FAX at 801-538-6382, or by Internet E-mail at mkgreen@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

04/02/2012

This rule may become effective on:

04/14/2012

Authorized by:

Michael Green, Policy and Training Coordinator

R367. Governor, Planning and Budget, Inspector General of Medicaid Services (Office of).

R367-1. Office of Inspector General of Medicaid Services.

R367-1-1. Introduction and Authority.

(1) This rule generally characterizes the scope of the Office of Inspector General of Medicaid Services in Utah, and defines all of the provisions necessary to administer the Office.

(2) The rule is authorized under Section 63J-4a-602 pursuant to Title 63G, Chapter 3, Utah Administrative Rulemaking Act.

(3) If any policy conflict arises between providers and or any party with regard to the Medicaid Program the Utah State Plan under Title XIX of the Social Security Act Medical Assistance Program shall be supreme and govern.

 

R367-1-2. Definitions.

(1) The terms used in this rule are defined in Section 63J-4a-102.

 

R367-1-3. The Office of Inspector General.

(1) The Utah Department of Health is the Single State Agency designated to administer or supervise the administration of the Medicaid program under Title XIX of the federal Social Security Act, The Office of Inspector General must ensure that the Medicaid Program is managed in an efficient and effective manner to minimize fraud, waste, and abuse, in the Medicaid program as outlined in Section 63J-4a-202. The Office of Inspector General has entered into a Memorandum of Understanding (MOU) with the Department outlining the delegation of duties from the Department to the Office and as required by federal and state statutes.

 

R367-1-4. Office Duties.

(1) The Office of the Inspector General shall perform the following duties:

(a) Adhere to appropriate standards as outlined in the Government Accounting Office's Government Auditing Standards.

(b) The Office will receive reports of potential fraud, waste, or abuse in the state Medicaid program through phone, website, or other electronic means open to the public:

(i) establish a 24-hour, toll free hotline monitored by staff, or voicemail as appropriate.

(ii) establish a separate identifiable email to report fraud, waste or abuse of Medicaid funds.

(c) The Office will investigate and identify potential or actual fraud, waste, or abuse in the state Medicaid program by post payment review of claims paid under fee-for service, managed care, capitation, waiver, contracts or other payment methods where funds are expended by the Department for Medicaid related services or programs.

(d) The Office will obtain, develop, and utilize computer algorithms to identify fraud, waste, or abuse in the state Medicaid program by either developing an in-house program, by contract with private vendors, or other suitable methods as agreed upon with the Department. The Office may also develop in-house programs in consultation with the Department.

(e) The Office will establish an MOU with the Medicaid Fraud Control Unit to identify and recover improperly or fraudulently expended Medicaid funds.

(f) The Office will determine appropriate methodology for identifying risk associated with the Division and its programs under Medicaid funding.

(g) The Office will regularly report to the Department regarding all identified cases of fraud, waste or abuse. The Office will report how the Department can reduce cost or improve performance through changes in policies or claims payment systems. The Office will operate the program integrity function and audit function to the extent possible and as described under a MOU with the Department to be established each state fiscal year beginning in July and ending In June of the following year. The MOU must be renewed each year by both the DOH and OIG.

(h) The Office will establish a means for providers to return payments to the Office. The Office will return all collected overpayments to the Department, except to pay Recovery Audit Contractors.

(i) The Office will provide training to agencies and employees on identifying potential fraud, waste, or abuse of Medicaid funds regularly. All training materials and curriculum will be developed in consultation with the Department and may include Department representation.

 

R367-1-5. Incorporations by Reference.

(1) All rules, regulations, and laws below are incorporated by reference.

(a) 42 CFR 431.107(b)(2)

(b) 42 CFR 456, Subpart B

(c) 42 CFR 455.13

(d) 42 CFR 455.21

(e) 42 CFR 1007

(f) 42 USC 139a(a)(3)

(g) 42 CFR 431, Subpart E

 

R367-1-6. Discrimination Prohibited.

(1) In accordance with Title VI of the Civil Rights Act of 1964 (42 USC 2000d et seq.), Section 504 of the Rehabilitation Act of 1973 (29 USC 70b), and the regulations at 45 CFR Parts 80 and 84, the Office assures that no individual shall be subjected to discrimination under the plan on the grounds of race, color, gender, national origin, or handicap.

 

R367-1-7. Utilization Review and Medicaid Services Provided under the Utah Medicaid Program.

(1) The Office may request records that support provider claims for payment under programs funded through the Department. These requests shall be in writing and identify the records to be reviewed. Written responses to requests must be returned within 30 days of the date of the written request. Responses must include the complete record of all services and supporting services for which reimbursement is claimed. If the provider is unable to produce the documents on request, the provider shall be granted 24 hours to provide all necessary and appropriate information supporting and documenting the need for services. However, if there is no response within the 30 day period, the Office will close the record and will evaluate the payment based on the records available.

(2) The Office may conduct announced or unannounced onsite reviews and visits. On-site reviews require that the provider submit records on request based on 42 CFR 431.107(b)(2). All announced visits will receive reasonable notice from the Office.

(3) The Office shall conduct hospital utilization reviews as outlined in the Department's Superior System Waiver in effect at the time service was rendered.

(a) The Office shall determine medical necessity and appropriateness of inpatient admissions during utilization review by use of InterQual criteria, published by McKesson Corporation, or another suitable industry standard substitute.

(b) The standards in the InterQual criteria, or other suitable industry standard substitute, shall not apply to services in which a determination has been made to utilize criteria customized by the Department or that are excluded as a Medicaid benefit by rule or contract.

(c) Where InterQual or other suitable industry standard substitute criteria are silent, the Office shall approve or deny services based upon appropriate administrative rules or the Department's criteria as incorporated in the Medicaid provider manuals.

(4) Providers shall refund payments to the Office upon written request if any of the following occur:

(a) the Department pays for a service which is later determined not to be a benefit of the Utah Medicaid program; or

(b) does not comply with state or federal policies and regulations.

(c) If services cannot be properly verified or when a provider refuses to provide or grant access to records.

(d) Unless appealed, all refunds must be made to the Office within 30 days of written notification. An appeal of this determination must be filed within 30 days of written notification as specified in Rule R367-1-6.

(e) A provider shall reimburse the Office for all overpayments regardless of the reason for the overpayment. Including, but not limited to agency errors, inadvertent errors, or other program errors. The Office may make a request to the Department to deduct an equal amount from future reimbursements.

(5) The Office may include monetary penalties, fees for auditing, interest including any applicable and reasonable fees that do not exceed 10% of the total cost of the recovery or identified overpayment.

 

R367-1-8. Provider and Client Agreements.

(1) The Department contracts with each provider who furnishes services under the Utah Medicaid Program.

(2) By signing a provider agreement with the Department, the provider agrees to follow the terms incorporated into the provider agreements, including policies and procedures, provider manuals, Medicaid Information Bulletins, and provider letters.

(3) By signing an application for Medicaid coverage, the client agrees that the Department's obligation to reimburse for services is governed by contract between the Department and the provider.

(4) The Office will adhere to the agreements between the provider and the Department as long as there is no violation of state and or federal regulations.

 

R367-1-9. Medicaid Fraud.

(1) The Office establishes and maintains methods, criteria, and procedures that meet all federal and state requirements for prevention, control of program fraud and abuse; and provider sanctioning and termination.

(2) The Office will enter into an MOU with The Medicaid Fraud Control Unit and the Department to ensure appropriate measures are established to reduce and prevent fraud and abuse in the Medicaid program.

 

R367-1-10. Confidentiality.

(1) Title 63G, Chapter 2, and Section 26-1-17.5 impose legal sanctions and provide safeguards that restrict the use or disclosure of information concerning providers, applicants, clients, and recipients to purposes directly connected with the administration of the plan. The Office will adopt those principles through incorporation of the references note.

 

R367-1-11. Right to Contract with Recovery Audit Organizations.

(1) The Office may contract for the investigation, notification and recovery of overpayments under any funds paid by the Department through the Medicaid program, Title XIX of the Social Security Act, under a contingency fee arrangement not to exceed the maximum amount set by CMS of the state's share actually recovered from overpayments according to federal regulations.

 

R367-1-12. Auditing of the Department of Health.

12.1. Audit Responsibilities.

(1) Audits will be conducted under the regular supervision of the Inspector General.

(2) The audit reports will then be released to the Director of the Governor's Office of Planning and Budget to which the Inspector General reports administratively.

(3) Audits will primarily be determined through a risk assessment approved by the Office.

(4) All activities of the Office will remain free of influence from any Department, Division, private or contracted entities.

(5) The Office audit group will follow the Generally Accepted Government AuditingStandards (GAGAS) as it relates to audit standards and training.

(6) The auditors will immediately notify the Inspector General of any serious deficiency or the suspicion of significant fraud during its review.

(7) Pursuant to Utah Code 63J-4a-301 the Office will have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating directly or indirectly to the state Medicaid program.

12.2. Audit Plan.

(1) An audit plan will be prepared by the Office at least annually and shall:

(a) Identify the audits to be performed, based on audit risk assessment reviewed annually;

(b) Identify resources to be devoted to audits in plan;

(c) Ensure that audits evaluate the efficiency and effectiveness of tax payer dollars in the Medicaid program;

(d) Determine adequacy of Medicaid's controls over federal and state compliance.

(2) An OIG audit shall:

(a) Issue regular audit reports on the effectiveness and efficiency of the defined audits within the Medicaid program in Utah;

(b) Ensure that such audits are conducted within professional standards such as those defined by the Institute of Internal Auditors and Generally Accepted Governmental Auditing Standards (GAGAS);

(c) Report annually to the Governor's office on or before October 1, and to the Utah Legislature before November 30 as stated in Section 63J-4a-502.

12.3. Access to Records and Employees.

(1) In order to fulfill the duties described in Section 63J-4a-202, the Office shall have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating, directly or indirectly, as stated in 63J-4a-301. Access to employees that the inspector general determines may assist in the fulfilling of the duties of the Office shall be granted as stated in 63J-4a-302.

12.4. Subpoena Power.

(1) The Office shall have the power to issue a subpoena to obtain record or interview a person that the Office has the right to access as stated in 63J-4a-401.

 

R367-1-13. Billing Codes.

(1) In submitting claims to the Department, every provider shall use billing codes compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA), along with other national accredited coding standards as defined under the federal law or other nationally accepted coding standards and as established under the Affordable Care Act of 2010 which requires all Medicaid providers to bill according to National Correct Coding Initiatives (N.C.C.I) that are in effect at the time of submitting claims to the Medicaid Agency for payments.

 

R367-1-14. Provider Communication.

(1) In completing the work as outlined in 63J -4a-202(k), to identify and recoup overpayments, the Office will communicate overpayments information as follows:

(a) Any suspected recoupment or take back against future funds less than $50,000 shall be communicated to the provider via email including a verification certificate attached to verify delivery.

(b) Any suspected recoupment or take back against future funds greater than $50,000 shall be communicated to the provider through certified mail or similar guaranteed delivery mechanism.

(c) Administrative hearing notice requirements will also comply with (a) and (b) above.

(d) In addition to the methods set forth in this rule, a party may be served as permitted by the Utah Rules of Civil Procedure.

(2) Any request for records or documents will also comply with subsections (a) through (d).

 

R367-1-15. Administrative Hearings.

(1) Introduction and Authority:

(a) This rule sets forth the administrative hearing procedures for the Office.

(b) This rule is authorized by Section 26-1-24, Section 63G-4-102, 42 USC 1396a(a)(3), and 42 CFR 431, Subpart E.

(2) Definitions:

(a) "Action" means a reduction, denial or revocation of reimbursement for services for a provider or any other action by the Office that affects the legal rights of a person or group of persons, but not including rules made under the Utah Administrative Rulemaking Act, Title 63G, Chapter 3.

(b) "Administrative Law Judge" or ALJ means the person appointed to conduct an adjudicatory proceeding.

(c) "Ex Parte Communication" means direct or indirect communication in connection with an issue of fact or law between the ALJ and one party only.

(d) A "Medical Record" is a record that contains medical data of a client.

(e) "Order" means a ruling by an ALJ that determines the legal rights, duties, privileges, immunities, or other legal interests of one or more specific persons.

(f) "Petitioner" means any group or individual who is adversely affected by any action or inaction of the Office.

(3) Computation of time: Unless otherwise provided in a specific section of these rules, time shall be computed in accordance with the Utah Rules of Civil Procedure.

(4) Request for Hearing:

(a) Petitioner may file a written request for agency action pursuant to Section 63G-4-201, and in accordance with this rule. If a medical issue is in dispute, each request should include supporting medical documentation. The Office will schedule a hearing only when it receives sufficient medical records and may dismiss a request for agency action if it does not receive supporting medical documentation in a timely manner.

(b) Hearings must be requested within 30 calendar days from the date that the Office sends written notice of its intended action.

(c) Failure to submit a timely request for a hearing constitutes a waiver of a Petitioner 's due process rights. The request must explain why the party is seeking agency relief, and the party must submit the request on the "Request for Hearing/Agency Action" form. The party must then mail or fax the form to the address or fax number contained on the notice of agency action.

(d) The Office considers a hearing request that a recipient sends via mail to be filed on the date of the postmark. If the postmark date is illegible, erroneous, or omitted, the Office considers the request to be filed on the date that the Office receives it, unless the sender can demonstrate through competent evidence that it was mailed before the date of receipt.

(5) Designation of Proceedings as Formal or Informal:

(a) A formal hearing will be set if the adverse action seeks reimbursement or other monetary sanctions in an amount of $100,000 or above. Formal hearings will be conducted as formal adjudicative proceedings in accordance with the Utah Administrative Procedure Act, Utah Code 63G-4-202, 204 through 209, 302, 401, 403, 405, 501 and 502.

(b) An informal hearing will be set if the adverse action seeks reimbursement or other monetary sanctions in an amount less than $100,000. Informal hearings will be conducted in accordance with the Utah Administrative Procedure Act, Utah Code 63G-4-202, 203, 209, 302, 401, 402, 405, 501, 502, 503, and 601.

(c) At any time before issuing a decision, the ALJ may convert an informal proceeding to a formal proceeding or a formal proceeding to an informal proceeding if conversion is in the public interest and does not unfairly prejudice the rights of any party.

(6) Service:

(a) The individual or party that files a document with the Office shall also serve the document upon all other named parties to the proceeding and file a proof of service with the Office that consists of a certificate, affidavit or acknowledgment of service.

(b) If the Office must provide notice of a formal hearing, the notice becomes effective on the date notification is sent.

(c) Section R367-1-14, Provider Communication, is incorporated under this sub-rule.

(7) Availability of Hearing:

(a) All requests for Hearings/Agency Action shall be set for an initial hearing in accordance with subsection 11.

(b) The Office will conduct an evidentiary hearing in connection with the agency action if the aggrieved person requests a hearing and there is a disputed issue of fact. If there is no disputed issue of fact, the ALJ may deny a request for an evidentiary hearing and issue a recommended decision without a hearing. There is no disputed issue of fact if the aggrieved person submits facts that do not conflict with the facts that the agency relies upon in taking action or seeking relief.

(c) The Office may deny or dismiss a request for a hearing if the aggrieved person:

(i) withdraws the request in writing;

(ii) verbally withdraws the hearing request at a prehearing conference;

(iii) fails to appear or participate in a scheduled proceeding without good cause;

(iv) prolongs the hearing process without good cause;

(v) cannot be located or agency mail is returned without a forwarding address; or

(vi) does not respond to any correspondence from the ALJ or fails to provide medical records that the agency requests.

(d) If the aggrieved person objects to the hearing denial, the person may raise that objection as grounds for relief in a request for reconsideration.

(8) Administrative Law Judge:

(a) The Inspector General shall appoint an impartial ALJ to conduct any hearing provided under these rules. Previous involvement in the initial determination of the action precludes an ALJ from appointment.

(b) The ALJ shall maintain order and may recess the hearing to regain order if a person engages in disrespectful, disorderly or disruptive conduct. The ALJ may remove any person, including a participant, from the hearing to maintain order. If a person shows persistent disregard for order and procedure, the ALJ may:

(i) restrict the person's participation in the hearing;

(ii) strike pleadings or evidence; or

(iii) issue an order of default.

(9) Modifying Requirements of Rules:

(a) Except as provided in this paragraph, the requirements of these rules may be modified by order of the ALJ for good cause.

(b) The requirements for timely filing a Request for Hearing under section (4) may not be modified.

(10) Ex Parte Communications:

(a) Ex parte communications are prohibited.

(b) The ALJ may not listen to or accept any ex parte communication. If a party attempts ex parte communication, the ALJ shall inform the offeror that any communication that the ALJ receives off the record will become part of the record and furnished to all parties.

(c) Ex parte communications do not apply to communications on the status of the hearing and uncontested procedural matters.

(11) The Informal Hearing:

(a) Unless otherwise provided in this section, informal hearings shall be conducted in accordance with Utah Code Section 63G-4-202 and 203.

(b) As set forth in subsection (7) all request for hearings/agency action shall be set for initial hearing within 30 days, only after at least 10-day notice of all parties.

(c) The Office shall notify the petitioner and Office representative of the date, time and place of the hearing at least ten days in advance of the hearing. Continuances of scheduled hearings are not favored, but may be granted by the president officer for good cause shown. Failure by a petitioner to appear at the hearing after notice has been given shall be grounds for default and shall waive both the right to contest the allegations and the right to the hearing.

(d) The party named in the notice of agency action and the Office shall be permitted to testify, present evidence, and comment on the issues. Formal rules of evidence shall not apply. The party that initiates the hearing process through a request for agency action has the burden of proof as the moving party. When a party possesses but fails to introduce certain evidence, the presiding officer may infer that the evidence does not support the party's position.

(e) Testimony may be taken under oath at the ALJ's discretion.

(f) All hearings are open to all parties.

(g) Discovery is prohibited; informal disclosures will be ruled on at the pre-hearing conference.

(h) Subpoenas and orders to secure the attendance of witnesses or the production of evidence shall be issued by the ALJ when requested by a petitioner or the Office, or may be issued by the ALJ on his/her own motion.

(i) A petitioner shall have access to relevant information contained in the Office's files and to material gathered in the investigation of petitioner to the extent permitted by law.

(j) The ALJ may cause an official record of the hearing to be made, at the Office's expense.

(k) Disposition of the ALJ's Order:

(i) Within a reasonable time after the close of the informal proceeding, the ALJ shall issue a signed order in writing that includes the following: the decision, the reasons for the decision, the Order, a notice of any right to administrative or judicial review of the order available to aggrieved parties and the time limits applicable to any reconsideration or review.

(ii) The order shall be based on the facts appearing in the Office's files and on the facts presented in evidence at the informal hearing.

(iii) A copy of the ALJ order shall be promptly mailed to each party.

(12) The Formal Hearing:

(a) The Office shall notify the parties of the date, time, and place of the hearing at least ten days in advance of the hearing. The ALJ's name, title, mailing address, and telephone number shall be provided to the parties. Failure to appear at the hearing after notice has been given shall be grounds for default and shall waive both the petitioner 's right to contest the allegations, and the petitioner 's right to the hearing.

(b) The ALJ shall regulate the course of the hearings to obtain full disclosure of relevant facts and to afford all the parties reasonable opportunity to present their positions, present evidence, argue, respond, conduct cross-examinations, and submit rebuttal evidence. The party that initiates the hearing process through a request for agency action has the burden of proof as the moving party. When a party possesses but fails to introduce certain evidence, the presiding officer may infer that the evidence does not support the party's position.

(c) Discovery

(i) the Utah Rules of Civil Procedure do not apply to formal adjudicative proceedings and formal discovery is permitted only as set forth in this section;

(ii) the scope of discovery in formal adjudicative proceedings, unless otherwise limited by order of the ALJ, is as follows:

(a) The Office may request copies of pertinent records. In the event the provider fails to produce the records within a reasonable time the Office may review all pertinent records in the custody of the provider during regular working hours after three days of written notice.

(b) The Office shall allow the aggrieved person or the person's representative to examine all Office documents and records upon written request to the Office at least 21 days before the hearing.

(c) An individual may request access to protected health information in accordance with Rule 380-250, which implements the privacy rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(d) The ALJ may permit the filing of formal discovery or take depositions only upon a clear showing of necessity that takes into account the nature and scope of the dispute. If the ALJ allows formal discovery, he/she shall set appropriate time frames for response and assess sanctions for non-compliance.

(e) The ALJ may order a medical assessment at the expense of the Office to obtain information. This information is subject to HIPAA confidentiality requirements and is part of the hearing record.

(f) The ALJ may set appropriate deadlines and page limits for any motions.

(g) The ALJ may require the filing of stipulations of facts, or pre-trial briefs, or pretrial disclosures.

(h) The ALJ may permit the parties to make oral arguments or submit additional briefs or memoranda after the close of the evidence .

(i) The ALJ may require each party to submit a post-hearing brief, and proposed findings of fact and conclusions of law.

(j) ALJs order shall comply with 63G-4-208.

(13) Declaratory Orders.

(a) Any person may file a request for Office action, requesting that the Office issue a declaratory order determine the applicability of a statute, rule, or order within the primary jurisdiction of the Office in accordance with 63G-4-503.

(b) Petition Form.

The petition shall:

(i) be clearly designated as a request for a declaratory order;

(ii) identify the statute, rule, or order to be reviewed;

(iii) describe the situation or circumstances giving rise to the need for the declaratory order or in which applicability of the statute, rule, or order is to be reviewed;

(iv) describe the reason or need for the applicability review;

(v) identify the person or agency directly affected by the statute, rule, or order;

(vi) include an address and telephone where the petitioner can be reached during regular work days; and

(vii) be signed by the petitioner.

(c) The provisions of Sections 63G-4-202 through 63G-4-302 apply to declaratory proceedings.

(d) The Office will not issue a declaratory order that deals with a question or request that the ALJ determines is:

(i) Not within the jurisdiction and competence of the Office;

(ii) trivial, irrelevant, or immaterial;

(iii) not one that is ripe or appropriate for determination;

(iv) currently pending or will be determined in an on-going judicial proceeding;

(v) prohibited by state or federal law; or

(vi) challenge the validity of a federal statute or regulation.

 

R367-1-16. General Rule Format.

(1) The following format is used generally throughout the rules of the Office. Section headings as indicated and the following general definitions are for guidance only. The section headings are not part of the rule content itself. In certain instances, this format may not be appropriate and will not be implemented due to the nature of the subject matter of a specific rule.

(2) Introduction and Authority. A concise statement as to what Medicaid service is covered by the rule, and a listing of specific federal statutes and regulations and state statutes that authorize or require the rule.

(3) Definitions. Definitions that have special meaning to the particular rule.

(4) Other Sections. As necessary under the particular rule, additional sections may be indicated. Other sections include regulatory language that does not fit into sections (1) through (4).

 

KEY: Inspector General, health, Medicaid fraud waste abuse

Date of Enactment or Last Substantive Amendment: 2012

Authorizing, Implemented, or Interpreted Law: 63J-4a-101; 63J-4a-201; 63J-4a-602