12VAC35-225-420: Appeal to the Department of Medical Assistance Services

A. In addition to the dispute resolution options described in this chapter, Medicaid or FAMIS recipients seeking to contest service decisions shall have the right to file an appeal with the Department of Medical Assistance Services pursuant to federal and state Medicaid law. If the individual is enrolled in a Medicaid managed care organization or "MCO," the internal appeal process for the Medicaid MCO must be exhausted or deemed exhausted before appealing to the Department of Medical Assistance Services. Appeals to the Department of Medical Assistance Services are separate from the dispute resolution options available under this chapter and shall comply with applicable Department of Medical Assistance Services' regulations.

B. A notice of action meeting federal and state requirements must be issued to the individual explaining the basis for the action and the right to appeal.

C. Families shall follow all applicable Department of Medical Assistance Services requirements when filing an appeal.