12VAC30-110-90: Right to appeal

An individual has the right to file an appeal when:

1. His application for benefits administered by the department is denied. However, if an application for State and Local Hospitalization coverage is denied because of a lack of funds which is confirmed by the hearing officer, there is no right to appeal;

2. The agency takes action or proposes to take action that will adversely affect, reduce, or terminate his receipt of benefits;

3. His request for a particular medical service is denied, suspended, reduced, or terminated, in whole or in part;

4. The agency fails to take an application and/or fails to act with reasonable promptness on his application for benefits or request for a particular medical service;

5. The agency takes action or proposes to take action regarding the recovery of applicable medical assistance payments from a decedent's estate;

6. The agency takes action or proposes to take action regarding the recovery of expenditures for services received by ineligible individuals;

7. The agency takes action or proposes to take action regarding the recovery of expenditures paid on behalf of individuals whose coverage was continued during the appeals process; or

8. Federal regulations require that a fair hearing be granted.