870.2 Requesting a Fair Hearing

Medical Assistance (MA) Expedited Fair Hearing, OPS170904 (Published September 29, 2017)

The individual or their representative may request a fair hearing by:

• completing and signing the appeal section of any notice;

• sending a written or faxed request to the CAO;

• telling the CAO; or

NOTE:  The individual must follow up with a written request within 3 days of the oral request unless it is a SNAP appeal. If a written request is not required or received, the CAO should document the oral request in a memo and send the memo to BHA.

• sending a written request to another provider or agency which notified the individual of a decision. The individual must request the fair hearing from the agency or provider which notified him of the decision. The agency or provider will forward the request to BHA.

NOTE:  Commonwealth Court decided that certain firms which assist MA individuals are not “collection agencies” and may represent individuals under power-of-attorney in the appeal process. (Nolan v. Department of Human Services, 673A.2d 413 (Pa.Cmwlth 1995)).

A faxed request for a hearing and the faxed Power of Attorney form are acceptable. Original copies are not required.

55 Pa. Code § 275.4(h)(2)   7 eCFR 273.15(h)

The CAO, agency, or provider will help the individual to request the hearing as follows:

• Clearly explain the reason for the action or decision which the individual is questioning.

• Provide an interpreter if needed.

NOTE:  If the individual needs an interpreter/transliterator at the hearing because of Limited English Proficiency (LEP) or a hearing impairment, BHA will arrange for an official interpreter/transliterator. The individual may bring a friend or relative to assist the client at the hearing, but the interpreter provided by BHA will be the official interpreter.

• Explain the procedure.

• Help write the request or fill out forms.

• Advise the individual that a friend, relative, attorney, legal services, or other spokesperson may represent him and include this individual in all discussions related to the appeal.

• Provide case record materials at the client's request.

Case information related to an appeal must be made available to an attorney or advocate who contacts a CAO if any of the following happens:

1. an authorization signed by the individual is provided.

2. the appeal form or another form indicates that the attorney or advocate is representing the individual

3. the client calls the CAO to say that the attorney or advocate is representing the individual.

4. the CAO calls the individual who confirms that the attorney or advocate is representing the individual.

5. the CAO knows the attorney or advocate who provides facts about the case, and the CAO can trust the claim that the attorney or advocate is representing/helping the client.

Case information released to an attorney or advocate based on 3, 4 or 5 above requires case narrative

Procedures in Chapter 930, Safeguarding Information, must be followed for any other request for case record information.

NOTE:  The CAO will provide materials, free of charge, which are related to the issue being appealed.

870.21 Processing a Request for a Fair Hearing

Upon receipt of a request for a fair hearing, the CAO, agency, or provider will:

• Date stamp all appeals received.

• Identify whether the appeal is expedited (i.e. Community Choice) and follow the expedited appeal process below (See Section 870.211, Expedited Community Choice Appeals Procedures).

For SNAP - Date stamp the written request. If the request is made orally, the CAO will write a memo and date stamp it with the date of the oral request. The individual is not required to write their request. Attach a copy of the notice for the proposed action.

55 Pa. Code § 275.4(h)(3)   7 CFR 273.15(b)

For Cash Assistance, Medical Assistance, Children’s Health Insurance Program (CHIP), and HCBS Services - Date stamp the written request. The request must specify the action being taken and be signed by the individual. If an oral request is made, help the individual write their request. If the oral appeal is not written and signed by the client within three working days after the oral appeal is made, the Bureau of Hearings and Appeals (BHA) may dismiss the appeal. The memo of the oral request must be forwarded to BHA for disposition.

• Review the request to be sure it includes identifying information, such as the case number, complete address, and name of the CAO.

• The CAO should assess the appellant’s need for LEP services and enter results on the appeal coversheet and in Enterprise Case Management (ECM).

• Access Enterprise Case Management (ECM) and complete the Create Appeal Request workflow, entering:

• • Appellant demographics (residential address, mailing address, any additional points of contact for the appellant)
  • Appeal details (CAO information, Expedited Fair Hearing request, and any additional appeal details)
  • Hearing details (Pre-hearing conference request, type of hearing requested, LEP services)
  • Digital attachments/physical exhibits

• Continue in ECM by completing the Submit Appeal Coversheet workflow, entering:

• • Appeal issue codes
  • OIM (and, if necessary OGC) information and point of contact
  • Request for hearing accommodations
  • Expedited hearing details
  • LEP support

• After the appeal request is submitted to BHA and goes through the perfecting process, ECM generates the hearing packet, with all pertinent documents, and mails it to the appellant.

• • Upload the fact sheet as described in Section 870.5 and the hearing request including a complete version of all adverse action notices including attachments and English translations if applicable to BHA via ECM within three working days from the date it is received and date stamped. Include the envelope in which the appeal came (or a copy with the postmark), and applicable OARS screens for overpayment appeals.

Exception: Upload in ECM an appeal of a denial of payment for an abortion to BHA within one working day or less. Ask this individual if they are willing to waive their right to notice 10 days prior to the date of the hearing and if they agrees to a telephone hearing instead of a face-to-face hearing. These waivers will allow BHA to make a decision within 30 days. The CAO will write the individual’s decision about the waivers and the phone number for the individual on the appeal request.

• If the hearing request is mailed to the CAO, make a copy of the postmarked envelope for the case record and submit electronically to the appeal in ECM. BHA considers the date of the date stamp as the filing date. BHA considers the postmarked date as the filing date only if it makes the appeal timely filed.

• If the hearing request is hand-delivered or completed in the CAO, BHA considers the date stamp as the filing date.

• If the hearing request is oral, the date the request is made is the filing date. Upload a copy of the agency’s notice with the memo, if applicable, into the ECM.

Reminder: For other than SNAP cases, the CAO will request the appellant to submit the appeal request in writing to BHA.

• Review the individual’s appeal to verify that the CAO's action was correct. If the action is incorrect, take corrective action. If the corrective action involves a payment, it may be retroactive to the date of the incorrect action. Send the individual a notice explaining the action.

NOTE:  Corrective action or payment does not interfere with or affect the individual’s right to proceed with the appeal. If the individual is satisfied with the corrective action and withdraws their request for a hearing, the CAO will contact BHA as soon as the CAO receives the written withdrawal signed by the client. The CAO will upload into ECM the signed written withdrawal. If the appeal is not scheduled, the CAO must upload the withdrawal into ECM.

55 Pa. Code § 275.4(h)(3)(ii)   7 eCFR 273.15(b)

• Offer the individual the opportunity for a face-to-face or telephone prehearing conference to attempt to resolve the appeal. See Section 870.13, Prehearing Conference.

• When the adverse action is the result of the individual's failure to keep an appointment for a recertification, redetermination or renewal, or ETP interview, and the individual requests another appointment, the CAO will schedule an appointment to attempt to resolve the appeal. In the interim, the appeal process proceeds.

• Determine if the individual has provided new or additional or acceptable verification of the eligibility factor at issue in the appeal. If the verification shows that the client met the eligibility factor as of the effective date of the adverse action, the CAO will restore benefits retroactive to the date of termination, denial, reduction, or suspension, provided all other conditions of eligibility are met.

NOTE:  If the verification submitted shows the client has met eligibility factors but the date is after the effective date of the adverse action, benefits will begin or be reinstated on the date eligibility is verified.

Example:

Mrs. Jones failed to keep a scheduled redetermination interview and to verify the family's eligibility for TANF, SNAP, and MA. The CAO sent a PA/FS 162-A dated January 7, advising Mrs. Jones that her benefits would be terminated effective January 21. On January 25, Mrs. Jones filed a timely appeal.  On February 2, prior to the hearing, Mrs. Jones provided acceptable verification establishing her family's continued eligibility for benefits.  Since Mrs. Jones provided verification to establish her eligibility as of the effective date of the closing, the CAO restored benefits retroactive to January 21.

• The CAO will make available to the individual and their representative, and will provide copies as requested, no later than five calendar days prior to the date of the scheduled hearing including hearings scheduled for expedited appeals:

• All information which the CAO intends to use as evidence.

• The names of CAO staff who expect to participate.

• The fact sheet.

• All exhibits.

NOTE:  Information mailed to the individual and their representative must be received no later than five calendar days prior to the scheduled hearing.

55 Pa. Code § 275.4(h)  7 CFR 273.15(p)

NOTE:  The CAO will notify other agencies/bureaus about appeals that require documentation and/or representation for the hearing from that agency. This includes Bureau of Employment and Training contractors and the Bureau of Child Support Enforcement. The CAO will provide the names of the staff member(s) from other agencies who will participate in the hearing and any documentation from the agency that will be presented at the hearing. This information must be provided to the individual and/or their representative at least five days prior to the date of the scheduled hearing.

NOTE:  If the CAO fails to submit the exhibits to the individual and their representative five days prior to the hearing, the CAO may:

• Lose the hearing.

• Be denied the ability to submit the exhibits at the hearing.

NOTE:  In specific instances, the CAO may request an exemption to the five-day time frame. The request must be processed through the Executive Director.

If there are any materials which the CAO believes should not be released because of confidentiality requirements, the CAO will send BHA a written summary including:

• the decision or action that the individual is appealing and the reasons for it;

• the specific document or subject matter the individual wants to examine; and

• The reasons for withholding the material.

The CAO will give the individual a copy of the summary. The individual may submit to BHA his reasons for requesting the materials.

The ALJ will determine if the material is relevant and if the CAO should give it to the individual. This decision cannot be appealed. If the CAO obtained information from the Office of General Counsel, any information provided is protected by client/attorney privilege and considered confidential. The CAO will not make the information part of the individual record and will not give it to the individual or any other individual or introduce it as evidence in a hearing. If the CAO specifically requests a document from the Office of General Counsel to use as evidence, that document is provided to the individual.

NOTE:  Requesting a decision from BHA does not negate the responsibility to provide materials to the client and/or representative no later than five days prior to the date of the hearing.

For CHIP – the Office of Medical Assistance Programs (OMAP) will conduct case reviews on certain CHIP appeals that are received by the CAO.  CHIP appeals will not always be sent to BHA to be scheduled for a hearing.  CAOs must review and code all appeals within 24 hours (1 Business Day).

CHIP Only Appeal

If the only decision being appealed is regarding an action taken that affected one or more CHIP budgets the CAO will take the following actions:

• Complete the Appeal Coversheet.
• Narrate and image the CHIP appeal to the case record with the appeal coversheet.
• Email the appeal, notice being appealed, and coversheet within 3 days to OMAP at RA-PWCHIP_Appeals@pa.gov. The subject line should state the case record number and the date the appeal was received (CO/Record – MM/DD/YY).
• Respond to requests from the CHIP ERO within three business days.

Once the appeal, notice and coversheet are sent to OMAP, the CAO responsibilities end.  This includes the pre-hearing conference, exhibits, and attendance at a hearing.

An OMAP benefit review officer will handle the appeal.  OMAP will communicate to the CAOs via the BHA liaison if the case needs re-opened of if further action is needed. 

If the CHIP household has questions regarding their CHIP-only appeal, has resolved the issue that caused the appeal, or would like to withdraw their appeal, the CAO should email RA-PWCHIP_Appeals@pa.gov with the individual’s contact information indicating they have questions regarding their appeal and request a call back.  Enter the record number and “individual question” or “withdraw” in the subject line.

Example: Household with two children receiving CHIP 00 moves to CHP 03 at renewal.  The payment name appeals.  Other than sending the appeal, notice, and coversheet to OMAP, there is no CAO responsibility.

CHIP Appeal with other Benefits (Appeal Related to Income)

If the household appeals multiple benefit decisions that includes a CHIP budget and the CHIP issue is income related, the CAO will be responsible for the entire appeal.  The original appeal and coversheet will be forwarded to BHA per the standard process outlined above under For Cash Assistance, Medical Assistance, and HCBS Service.

The CAO must follow all BHA processes including completing the pre-hearing conference and attending the hearing for all portions of the appeal in this scenario.

Example: Household open FS 00 with one child receiving MG 00 and another receiving CHP 00.  New income reported at renewal causes FS 00 to close and both children to move to CHP 03.  The family appeals.  This appeal will be sent to BHA and remains the responsibility of the CAO for all budgets.

CHIP Appeal with other Benefits (Non-financial Appeal)

If the household appeals several benefit decisions that include a CHIP budget and the CHIP issue is related to non-financial criteria (failure to pay premium, failure to provide verification, age 19, etc.), the appeal will be split into two appeals.  The CAO remains responsible for the pre-hearing conference, attending the hearing, and all other BHA processes for the non-CHIP appeal.  CHIP budgets will be in a separate appeal to OMAP.

• The original appeal and coversheet, with non-CHIP budgets, will be forwarded to BHA per standard process outlined above under For Cash Assistance, Medical Assistance, and HCBS Service.  The CAO remains responsible for the pre-hearing conference, attending the hearing, and all other BHA processes for the non-CHIP portion of the appeal.
• The CHIP appeal, notice being appealed, and the appeal coversheet will be sent to OMAP at RA-PWCHIP_Appeals@pa.gov.
  1. Complete two Appeal Coversheets.
  2. Prepare the appeal packets with the appeal request, appealed notice, and coversheet. One packet will be for any non-CHIP budgets and the second will be for the CHIP budgets.
  3. Narrate the appeal receipt and image both appeal packets.
  4. Enter the appeal for the non-CHIP budgets in ECM. The CAO must follow all BHA processes including completing the prehearing conference and attending the hearing for non-CHIP budgets in the appeal.
  5. The CHIP budget appeal is no longer required to be entered into MAPPER.
  6. Email the CHIP appeal request, appealed notice , and coversheet within 3 days to OMAP at RA-PWCHIP_Appeals@pa.gov.  The subject line should state the case record number and the date the appeal was received (CO/Record – MM/DD/YY). Respond to requests from the CHIP ERO within three business days.
  7. Respond to requests from the CHIP ERO within three business days.

Once the CHIP appeal, notice and coversheet are sent to OMAP, the CAO responsibilities end.  This includes the pre-hearing conference, exhibits, and attendance at a hearing.

An OMAP benefit review officer will handle the appeal.  OMAP will communicate to the CAOs via the BHA liaison if the case needs re-opened of if further action is needed. 

If the CHIP household has questions regarding their CHIP-only appeal, has resolved the issue that caused the appeal, or would like to withdraw the appeal, the CAO should email RA-PWCHIP_Appeals@pa.gov with the individual’s contact information indicating they have questions regarding their appeal and request a call back.  Enter the record number and “individual question” or “withdraw” in the subject line.

Example: Household open FS 00 with one child receiving MG 00 and another receiving CHP 00.  Renewal is not returned and cannot be reviewed ex parte, causing all benefits to close 042.  The family appeals.  This appeal will be split.  There will be one appeal held by the CAO for FS 00 and MG 00, and a separate appeal sent to OMAP for CHIP.

CHIP – Appeal Issue codes:

870.211 Expedited Community Choice Appeals Procedures

The individual has the choice of submitting a request for an appeal hearing under the existing process or under an expedited process. The CAO will provide written notification of the option of an expedited appeal process to all individuals whose Medicaid eligibility is denied or terminated.

NOTE:  Even though the Waiver programs administered by the Office of Mental Retardation (Consolidated; Infants, Toddlers and Family; and Person, Family Directed Support Waivers) are not currently a part of the Community Choice process, consumers participating in these programs are entitled to the choice of the expedited appeals process for a denial/termination of Medicaid eligibility.

The CAO is responsible for scheduling the expedited telephone appeal hearing. The hearings may be scheduled for:

• Tuesdays between 9:00 a.m. and 3:00 p.m.

• Thursdays between 9:00 a.m. and 3:00 p.m.

NOTE:  The CAO staff does not need to be concerned if more than one expedited appeal hearing is scheduled at one time slot. The BHA will be able to accommodate more than one expedited appeal hearing at a designated time slot.

The CAO will notify the BHA site administrator of the scheduled expedited appeal hearing both via a phone call and follow-up fax.

The CAO must complete the following within two business days of the receipt of the written request for an expedited appeal:

• Review the denial/termination of eligibility for Medicaid.

• Contact the individual (Supervisor only).

• Schedule an expedited appeal hearing.

BHA will conduct the appeal and hand down a decision within 10 business days of the date the CAO receives the written request for an expedited appeal process.

870.22 Processing an Appeal to Request a Fair Hearing for an Overpayment

CAOs that receive requests to appeal a decision of overpayments will continue to enter the appeal information into ECM.

Within one business day following the BHA ECM update, CAOs will fax a copy of the individual’s appeal request to the Office of Inspector General (OIG) Hearings and Appeals Coordinator at (717) 772-4986.

The OIG will enter the individual’s appeal information into the OIG Avoidance and Recovery System(OARS) within one business day of receipt and if appealed timely, suspend collection activities until a fair hearing decision is rendered or the individual withdraws the appeal.

Post-hearing processing is not affected by this change.

Updated September 19, 2024, replacing  August 21, 2018