# COMAR Title 10 — Maryland Department of Health

## Subtitle 02 — Division of Reimbursements

### Chapter 03 — Appeal Hearings to the Division of Reimbursements

**Authority:** Health-General Article, §2-207, Annotated Code of Maryland

**Administrative History:** Effective date: July 1, 1971

**Administrative History:** Regulation .01 amended effective June 28, 1999 (26:13 Md. R. 1019)

**Administrative History:** Regulations .01, .02C, and .03A amended effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .01B amended effective March 14, 2016 (43:5 Md. R. 385)

**Administrative History:** Regulation .03-1 adopted effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .04B, C amended effective June 28, 1999 (26:13 Md. R. 1019)

**Administrative History:** Regulation .06B amended effective May 5, 1986 (13:9 Md. R. 1028); June 28, 1999 (26:13 Md. R. 1019)

**Administrative History:** Regulation .06C amended effective May 5, 1986 (13:9 Md. R. 1028)

**Administrative History:** Regulation .08A, C amended effective June 28, 1999 (26:13 Md. R. 1019)

#### Regulation .01 Definitions.

*COMAR 10.02.03.01*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Administrative law judge” means an individual appointed by the Chief Administrative Law Judge under State Government Article, §9-1604, Annotated Code of Maryland, or designated by the Chief Administrative Law Judge under State Government Article, §9-1607, Annotated Code of Maryland.

  (2) “Appellant” means any individual who requests an appeal hearing for the reasons specified in Regulation .02, of this chapter.

  (3) “Chargeable person” means any responsible relative and, except for a recipient of services, any other person who is legally responsible in an individual or representative capacity for the care of the individual.

  (4) “Division” means the Division of Reimbursements of the Maryland Department of Health.

  (5) Recipient of Services.

    (a) “Recipient of services” means an individual who receives care, maintenance, treatment, or support in a facility or program that is operated or funded wholly or partly by the Department.

    (b) “Recipient of services” includes, but is not limited to an individual:

      (i) In a public facility under Health-General Article, Title 10, Annotated Code of Maryland;

      (ii) In a facility or Veterans Administration hospital for comprehensive evaluation under the Health-General Article, Title 7, Annotated Code of Maryland;

      (iii) In a residential, public facility or a facility from which this State obtains residential care under Health-General Article, Title 7, Annotated Code of Maryland; and

      (iv) In a facility operated under Public Health Services.

  (6) “Responsible relative” means the:

    (a) Spouse of a recipient of services;

    (b) Parents of a recipient of services who is a minor; and

    (c) Children of a recipient of services.

#### Regulation .02 Opportunity for an Appeal Hearing.

*COMAR 10.02.03.02*

An opportunity for an appeal hearing shall be granted when:

A. A rate is established (or increased) against an individual in an amount which is deemed by the individual to be arbitrary and excessive in accordance with the individual's financial circumstances;

B. An individual is aggrieved by any division policy, action, or inaction:

  (1) Which affects the charges established or manner of billing; or

  (2) Results in an increase in the rates established;

C. In the judgment of a recipient of services, responsible relative, or other chargeable person, he or she is adversely affected by any other Division policy, action, or inaction.

#### Regulation .03 Notification of Right to Request an Appeal Hearing.

*COMAR 10.02.03.03*

A. Whenever the Division conducts an investigation of an individual's financial resources and issues a notice of rate establishment for services rendered to a recipient of services in accordance with COMAR 10.02.01.05, the Division shall provide written notification to the individual of his or her right to seek an informal review or an appeal, or both, from the rates established by the Division.

B. The notification specified in §A of this regulation shall:

  (1) Advise the individual of the matters which are the proper subject of an appeal hearing as provided in Regulation .02, of this chapter;

  (2) Advise the individual of his right to be represented by a lawyer or other person of his choice during the entire hearing process;

  (3) Advise the individual that he may present witnesses and documents in his behalf at the hearing.

#### Regulation .03-1 Request for a Rate Review.

*COMAR 10.02.03.03-1*

A. If a recipient of services or other chargeable person submits a written request that the Division review the notice of rate establishment, the financial agent for the Division shall:

  (1) Review the notice of rate establishment to determine the accuracy of the charges established;

  (2) Review all pertinent information presented by the individual to determine if any adjustments in the billing are appropriate under these regulations;

  (3) Provide the individual with a final billing statement which indicates both the:

    (a) Division's position with regard to any written claims for a reduction in the rate established by the Division which are submitted by the individual to the financial agent; and

    (b) Final rates established by the Division for services rendered to a recipient of services.

B. The recipient of services or chargeable person shall have such rights as are set forth in Regulation .05, of this chapter, to request an appeal hearing regarding the Division's informal rate review and the charges for services established by it. In order to note an appeal from the charges established pursuant to the informal rate review, the recipient of services or chargeable person shall follow the procedures as set forth in Regulation .05, of this chapter.

#### Regulation .04 Request for an Appeal Hearing.

*COMAR 10.02.03.04*

A. Any individual, either himself or through a representative, may request an appeal hearing by giving a clear statement, in writing, to any financial agent of the Division that he desires an opportunity to present for review any matter which is the proper subject of an appeal hearing as provided in Regulation .02. This statement shall be forwarded immediately to the Chief of Reimbursements. When the Division receives a request for a hearing, it shall assist the appellant in submitting and processing the request.

B. The Division shall promptly acknowledge any request for an appeal hearing and shall thereafter set forth in writing the date, time, and place of the appeal hearing, after consulting with the Office of Administrative Hearings. The acknowledgement shall include the information specified in Regulation .03B of this chapter.

C. If any party notifies the Division that the time designated by the Division is not convenient to the party, and requests a different time for the hearing, the Office of Administrative Hearings shall designate another time convenient to the parties if it deems that the party has sufficient reason for requesting the change.

D. A request for an appeal hearing may not be granted unless it is made within 30 days of the receipt of the notification specified in Regulation .03A of this chapter or, if Regulation .03A does not apply, within 30 days following the conclusion of the action or inaction which is the subject of the appeal.

E. The Division may dismiss a request for an appeal hearing when it has been withdrawn in writing by the appellant or his representative, or abandoned. An appellant shall be deemed to have abandoned his request if he does not appear for the hearing on the established date.

#### Regulation .05 Pre-Hearing Procedures.

*COMAR 10.02.03.05*

The appellant and the Division may request the names of all witnesses that the other party intends to call at the hearing.

#### Regulation .06 Hearing Procedures.

*COMAR 10.02.03.06*

A. The appellant and the Division shall have the opportunity to present witnesses, documentary evidence, and oral and written argument, and to cross-examine all adverse witnesses.

B. If the appellant wishes to call as witnesses any of the Division's current employees, or former employees who reside within the State, whose action or inaction is being contested by the appellant or whose testimony is, in the judgment of the appellant, relevant to the issues under consideration, the Office of Administrative Hearings shall require their presence at the hearing. If the appellant has knowledge of the names or other identifying descriptions of the employees before the hearing, the appellant shall supply the Office of Administrative Hearings with the names or other identifying descriptions at least 5 days before the hearing. Subpoenas may be issued under COMAR 28.02.02.11.

C. If the Division introduces, as evidence, documents from the case record, special investigation file, or other sources, the appellant shall have the opportunity to examine persons who prepared the documents and to examine the case record or special investigation file for the purpose of discovering information favorable to his case. If these persons are no longer employees of the Division, the appellant shall be permitted to examine a Division representative familiar with the documents and applicable Division policies.

#### Regulation .07 The Record.

*COMAR 10.02.03.07*

A. A recording of the hearing shall be made. A copy of the recording shall be supplied to the appellant whenever the appellant takes a further appeal. The recording, together with all exhibits and papers admitted into evidence, shall constitute the exclusive record for decision. Nonrecorded or confidential information which the appellant does not have an opportunity to hear or see may not be made a part of the hearing record.

B. The recording and copies of all exhibits and papers shall remain in the custody of the hearing officer for a period not to exceed 2 years, or until all litigation involving the decision is terminated.

#### Regulation .08 Findings, Conclusions and Decisions.

*COMAR 10.02.03.08*

A. The administrative law judge shall prepare a written summary of findings and conclusions, based exclusively on the record, and shall make a recommendation based on those findings and conclusions. The summary of findings and conclusions shall state the policies, regulations, or laws upon which the decision is based.

B. A copy of the findings, conclusions and decisions shall be forwarded to the appellant or his representatives no later than 60 days after the date of the hearing.

C. The recommendation of the administrative law judge, after approval by the Secretary of Health, shall be final and binding upon the Division and shall be implemented immediately unless otherwise specifically indicated in the decision. When the hearing decision is favorable to the appellant, or when the Division grants the relief the appellant requests before the hearing decision, the Division, where applicable, shall authorize corrected billing or other relief retroactive to the date the incorrect action was taken.

D. The decision, if not favorable to the appellant, may be appealed to the Board of Review as provided by law in Health-General Article, §2-207, Annotated Code of Maryland.

E. Subsequent appeals, as provided by law, may be taken by the appellant.