§ 1187.34. Requirements related to notices and payments pending resident appeals.
(a) The requirements relating to notices authorizing and discontinuing MA payments for nursing facility services are as follows:
(1) Notices authorizing MA payment.
(i) The nursing facility shall retain, in its business office, a copy of the Department’s notice authorizing MA nursing facility services for each MA conversion resident and for each MA applicant or recipient who is admitted as a resident.
(ii) The Department’s notice authorizing MA nursing facility services will specify the effective date of coverage and the amount of money that the resident has available to contribute towards payment. The nursing facility is responsible to obtain the resident’s share of the payment.
(2) Notices discontinuing MA payment.
(i) The nursing facility shall retain, in its business office, a copy of the Department’s notice discontinuing payment for MA nursing facility services for every resident who the Department determines is no longer eligible to receive MA nursing facility services. The Department’s determination may be based upon a review conducted by the Department or the resident’s attending physician.
(ii) The Department’s notice discontinuing payment for MA nursing facility services will specify the effective date of the discontinuance of coverage, that the resident may appeal the notice within 30 days and that the resident must appeal within 10-calendar days of the date the notice was mailed in order for payments to continue pending the outcome of the hearing on the resident’s appeal.
(b) The requirements relating to payments pending resident appeals and recovery of payments subsequent to appeals are as follows:
(1) Payments pending appeal.
(i) If the resident or a representative of the resident appeals the Department’s notice discontinuing payment for MA nursing facility services within 10-calendar days of the date on which the notice was mailed to the resident, the Department will continue payments to the nursing facility for nursing facility services rendered to the resident pending the outcome of the hearing on the resident’s appeal subject to paragraph (2).
(ii) If the resident or a representative of the resident does not appeal the Department’s notice discontinuing payment for MA nursing facility services, or appeals after 10-calendar days from the date on which the notice was mailed to the resident, the Department will cease payment to the nursing facility for services rendered to the resident beginning on the effective date of the discontinuance of coverage specified in the notice or the date on which the resident was discharged from the facility, whichever date occurs first.
(2) Payment recovery for services rendered pending appeal. If a resident’s appeal of a notice of discontinuance of payment for MA nursing facility services is denied, the Department will recover payments made to the nursing facility. The period for which the Department will recover payments will begin on the effective date of the discontinuance of coverage specified in the notice to the resident and end on the date on which payments were discontinued as a result of the outcome of the hearing on the resident’s appeal or the date of the resident’s discharge from the facility, whichever date occurs first.
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