House Study Bill 151 HOUSE FILE BY (PROPOSED COMMITTEE ON HUMAN RESOURCES BILL BY CHAIRPERSON SMITH) Passed House, Date Passed Senate, Date Vote: Ayes Nays Vote: Ayes Nays Approved A BILL FOR 1 An Act relating to providing an appeal process for medical 2 assistance providers. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 1837YC 82 5 pf/je/5 PAG LIN 1 1 Section 1. NEW SECTION. 249A.36 PROVIDER APPEALS 1 2 PROCESS. 1 3 1. Notwithstanding conflicting provisions of chapter 17A, 1 4 a provider appeal hearing pursuant to subsection 2 shall be 1 5 available to a provider if any of the following conditions, 1 6 which constitutes a contested case, is met: 1 7 a. The provider's license, certification, registration, 1 8 approval, or accreditation has been denied or revoked or has 1 9 not been acted upon in a timely manner. 1 10 b. The provider's claim for payment or request for prior 1 11 authorization of payment has been denied. 1 12 c. The provider's contract as a medical assistance patient 1 13 manager has been terminated. 1 14 d. The provider has been notified that an overpayment has 1 15 been established and repayment is requested. 1 16 e. The provider has been notified that the reconsideration 1 17 process has been exhausted and the provider is not satisfied 1 18 with the result. 1 19 f. The provider's claim for payment was not made according 1 20 to department policy. 1 21 g. The provider's application for a child care quality 1 22 rating has not been acted upon in a timely manner, the 1 23 provider disagrees with the department's quality rating 1 24 decision, or the provider's certificate of quality rating has 1 25 been revoked. 1 26 2. a. A provider appeal hearing shall be conducted by a 1 27 panel which consists of the following members: 1 28 (1) One member, appointed by the president or presiding 1 29 officer of the provider's professional or trade association, 1 30 who is either a member of the association or is a provider who 1 31 provides similar professional services as the provider. For 1 32 the purposes of this subparagraph, "provider's professional or 1 33 trade association" means the entity composed of providers who 1 34 hold the same license, certification, registration, approval, 1 35 or accreditation as the provider or, if not licensed, 2 1 certified, registered, approved, or accredited, providers who 2 2 provide the same professional services as the provider. 2 3 (2) One member, appointed by the department, who is an 2 4 employee of the department. 2 5 (3) One member, who is an administrative law judge, 2 6 assigned by the division of administrative hearings of the 2 7 department of inspections and appeals in accordance with the 2 8 provisions of section 10A.801. 2 9 b. The administrative law judge member of the panel shall 2 10 be the presiding officer for the hearing. 2 11 c. The decision of the panel shall be determined by a 2 12 majority vote. 2 13 d. The decision of the panel shall be a final decision and 2 14 shall meet the requirements of a final decision pursuant to 2 15 section 17A.16. 2 16 e. A party to the hearing may file a request for rehearing 2 17 pursuant to section 17A.16. 2 18 f. A party who is aggrieved or adversely affected by a 2 19 final decision under this section is entitled to judicial 2 20 review as provided in section 17A.19. 2 21 EXPLANATION 2 22 This bill provides an appeals process for medical 2 23 assistance providers in certain contested case proceedings. 2 24 The bill specifies the circumstances, that constitute a 2 25 contested case, in which the alternative appeals hearing 2 26 process would apply. Under the alternative appeals hearing 2 27 process, in lieu of selection of a presiding officer for a 2 28 contested case proceeding under Code chapter 17A, which would 2 29 allow for an agency or an administrative law judge to preside, 2 30 the bill provides that the contested case would be presided 2 31 over by a panel made up of three members: a member appointed 2 32 by the provider's professional or trade association who is a 2 33 member of the association or a provider who provides similar 2 34 professional services as the provider; a member, appointed by 2 35 the department of human services, who is an employee of the 3 1 department; and an administrative law judge assigned by the 3 2 division of administrative hearings of the department of 3 3 inspections and appeals. The administrative law judge is to 3 4 be the presiding officer for the hearing and the decision of 3 5 the panel is to be determined by a majority vote. Under the 3 6 bill, the decision of the panel is a final decision, a party 3 7 to the hearing may file a request for rehearing, and a party 3 8 who is aggrieved or adversely affected by a final decision is 3 9 entitled to judicial review. 3 10 LSB 1837YC 82 3 11 pf:nh/je/5