Virginia regulations · Through 2026 Regular Session (effective July 1, 2026)

12VAC30-141-720: Request for appeal

A. Requests for  internal appeal of  MCO adverse  benefit determinations shall be submitted orally or in writing to the  MCO. Unless the enrollee requests an expedited appeal, an oral appeal request must be followed by a written appeal request. The enrollee must exhaust the MCO's internal appeals process before appealing to DMAS.

B. If the MCO fails to adhere to the notice or timing requirements set forth in this part, the enrollee is deemed to have exhausted the MCO's internal appeals process and may initiate a state fair hearing.

C. Requests for  appeal of adverse actions made by the  LDSS,  CPU, or DMAS, or of internal appeal decisions by the MCO shall be submitted  to DMAS.

D. Any  communication  expressing a desire to have an adverse  benefit determination by an MCO reviewed shall be treated as a request for  an internal appeal. Any communication expressing a desire to have an adverse action by the LDSS, CPU, or DMAS reviewed shall be treated as a request for a state fair hearing. Any communication expressing a desire to have an MCO internal appeal decision reviewed shall be treated as a request for a state fair hearing.

E. To be timely, requests for  an internal appeal of  an MCO's adverse benefit determination shall be received by the  MCO no later than  60 calendar days from the date of the  MCO's notice of adverse  benefit determination.

F. To be timely, requests for an appeal of an adverse benefit determination upheld in whole or in part by the MCO's internal appeal decision shall be received by DMAS within 120 calendar days from the date of the internal appeal decision.

G. To be timely, requests for  appeal of a local department of social services, DMAS, or CPU  adverse action shall be filed with DMAS no later than 30 calendar days from the date of the  notice of adverse action. Requests for  appeal of  an agency determination shall be considered filed with DMAS on the date the request is postmarked if mailed, or on the date the request is received if delivered other than by mail, by DMAS.

Where this section sits in the code

Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 141. Family Access to Medical Insurance Security Plan
Part VII. FAMIS MOMS

A. Requests for internal appeal of MCO adverse benefit determinations shall be submitted orally or in writing to the MCO. Unless the enrollee requests an expedited appeal, an oral appeal request must be followed by a written appeal request. The enrollee must exhaust the MCO's internal appeals process before appealing to DMAS.

C. Requests for appeal of adverse actions made by the LDSS, CPU, or DMAS, or of internal appeal decisions by the MCO shall be submitted to DMAS.

D. Any communication expressing a desire to have an adverse benefit determination by an MCO reviewed shall be treated as a request for an internal appeal. Any communication expressing a desire to have an adverse action by the LDSS, CPU, or DMAS reviewed shall be treated as a request for a state fair hearing. Any communication expressing a desire to have an MCO internal appeal decision reviewed shall be treated as a request for a state fair hearing.

E. To be timely, requests for an internal appeal of an MCO's adverse benefit determination shall be received by the MCO no later than 60 calendar days from the date of the MCO's notice of adverse benefit determination.

G. To be timely, requests for appeal of a local department of social services, DMAS, or CPU adverse action shall be filed with DMAS no later than 30 calendar days from the date of the notice of adverse action. Requests for appeal of an agency determination shall be considered filed with DMAS on the date the request is postmarked if mailed, or on the date the request is received if delivered other than by mail, by DMAS.

Collected 2026-09-14T04:51:16Z. Source file · JSON

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