Statutes, codes, and regulations
NORTH CAROLINA ADMINISTRATIVE CODE
Title 10A - HEALTH AND HUMAN SERVICESChapter 27 - MENTAL HEALTH, COMMUNITY FACILITIES AND SERVICESSubchapter I - AREA AUTHORITY OR COUNTY PROGRAM REQUIREMENTS
Section .0600 - NON-MEDICAID APPEAL PROCESS
Section 27I .0605 - DIVISION'S INITIAL RESPONSE TO A NON-MEDICAID APPEAL

10A N.C. Admin. Code 27I.0605

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Current through Register Vol. 39, No. 9, November 1, 2024
Section 27I .0605 - DIVISION'S INITIAL RESPONSE TO A NON-MEDICAID APPEAL
(a) The Director shall screen the request for appeal to the Division to determine:
(1) if the appeal was reviewed by the LME-MCO, area authority or county program according to the area authority or county program policy and procedures;
(2) if the appeal includes the denial, reduction, suspension or termination of a non-Medicaid state funded service;
(3) if the appeal falls within the scope of Rule .0601 of this Section; and
(4) if the appeal was filed in accordance with the requirements of Rule .0603 of this Section.
(b) The Director shall send an acknowledgement letter to the client, or the client's legally responsible person, and the LME- MCO, area authority or county program within 5 business days of receipt of the request for appeal to the Division.
(c) The acknowledgement letter shall specify whether the appeal has been accepted or not. The Division shall accept an appeal if it meets the standards as set forth in Paragraph (a) of this Rule.
(d) The Director shall notify the LME-MCO, area authority or county program and the client, or the client's legally responsible person, whose appeal is accepted for review, to submit all documentation considered during the LME-MCO, area authority or county program review to the Division no later than 10 calendar days from the date of the acknowledgement letter. Documentation shall be submitted to the DMHDDSUS Hearing Office, 3001 Mail Service Center, Raleigh, NC 27699-3001 or via fax at (984) 777- 9264. The acknowledgment letter shall advise the parties that a Hearing Officer will conduct a hearing.
(e) An appeal that does not meet the criteria as set forth in Paragraph (a) of this Rule shall be returned to the client as denied with an explanation of the basis for denial.
(f) If the appeal is denied on the basis of Subparagraph (a)(1) of this Rule, the LME-MCO, area authority or county program shall review the appeal in accordance with the requirements of Rule 10A NCAC 27G .7004.
(g) The client, or the client's legally responsible person, shall have 11 calendar days from the date of the LME-MCO, area authority or county program clinical review decision to resubmit the appeal to the Division.

10A N.C. Admin. Code 27I .0605

Authority G.S. 143B-147;
Eff. October 1, 2006;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.
Authority G.S. 143B-147;
Eff. October 1, 2006.
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017;
Amended by North Carolina Register Volume 38, Issue 23, June 3, 2024 effective 5/1/2024.