Subdivision 1. Scope. A provider may appeal from a determination of a payment rate established pursuant to this chapter or allowed costs under chapter 256R if the appeal, if successful, would result in a change to the provider's payment rate or to the calculation of maximum charges to therapy vendors as provided by section 256R.54. Appeals must be filed in accordance with procedures in this section. This section does not apply to a request from a resident or long-term care facility for reconsideration of the classification of a resident under section 144.0722.
Subd. 1a. Definitions. (a) For the purposes of this section, the following terms have the meanings given.
(b) "Determination of a payment rate" means the process by which the commissioner establishes the payment rate paid to a provider pursuant to this chapter, including determinations made in desk audit, field audit, or pursuant to an amendment filed by the provider.
(c) "Provider" means a nursing facility as defined in section 256R.02, subdivision 33, or a facility as defined in section 256B.501, subdivision 1.
(d) The definitions in section 256R.02 apply to this section.
Subd. 1b. Filing an appeal. To appeal, the provider shall file with the commissioner a written notice of appeal; the appeal must be postmarked or received by the commissioner within 60 days of the publication date printed on the rate notice. The notice of appeal must specify each disputed item; the reason for the dispute; the total dollar amount in dispute for each separate disallowance, allocation, or adjustment of each cost item or part of a cost item; the computation that the provider believes is correct; the authority in statute or rule upon which the provider relies for each disputed item; the name and address of the person or firm with whom contacts may be made regarding the appeal; and other information required by the commissioner.
Subd. 1c. Contested case procedures appeals review process. (a) Effective for desk audit appeals for rate years beginning on or after July 1, 1997, and for field audit appeals filed on or after that date, the commissioner shall review appeals and issue a written appeal determination on each appealed item within one year of the due date of the appeal. Upon mutual agreement, the commissioner and the provider may extend the time for issuing a determination for a specified period. The commissioner shall notify the provider by first class mail of the appeal determination. The appeal determination takes effect 30 days following the date of issuance specified in the determination.
(b) In reviewing the appeal, the commissioner may request additional written or oral information from the provider. The provider has the right to present information by telephone, in writing, or in person concerning the appeal to the commissioner prior to the issuance of the appeal determination within six months of the date the appeal was received by the commissioner. Written requests for conferences must be submitted separately from the appeal letter. Statements made during the review process are not admissible in a contested case hearing absent an express stipulation by the parties to the contested case.
(c) For an appeal item on which the provider disagrees with the appeal determination, the provider may file with the commissioner a written demand for a contested case hearing to determine the proper resolution of specified appeal items. The demand must be postmarked or received by the commissioner within 30 days of the date of issuance specified in the determination. A contested case demand for an appeal item nullifies the written appeal determination issued by the commissioner for that appeal item. The commissioner shall refer any contested case demand to the Office of the Attorney General.
(d) A contested case hearing must be heard by an administrative law judge according to sections 14.48 to 14.56. In any proceeding under this section, the appealing party must demonstrate by a preponderance of the evidence that the determination of a payment rate is incorrect.
(e) Regardless of any rate appeal, the rate established must be the rate paid and must remain in effect until final resolution of the appeal or subsequent desk or field audit adjustment.
(f) To challenge the validity of rules established by the commissioner pursuant to this section and sections 256B.421, 256B.431, 256B.48, 256B.501, 256B.502, 256R.01, 256R.06, 256R.11, and 256R.12, a provider shall comply with section 14.44.
(g) The commissioner has discretion to issue to the provider a proposed resolution for specified appeal items upon a request from the provider filed separately from the notice of appeal. The proposed resolution is final upon written acceptance by the provider within 30 days of the date the proposed resolution was mailed to or personally received by the provider, whichever is earlier.
(h) The commissioner may use the procedures described in this subdivision to resolve appeals filed prior to July 1, 1997.
Subd. 1d. [Repealed, 1997 c 107 s 19]
Subd. 1e. Attorney fees and costs. (a) Notwithstanding section 15.472, paragraph (a), for an issue appealed under subdivision 1, the prevailing party in a contested case proceeding or, if appealed, in subsequent judicial review, must be awarded reasonable attorney fees and costs incurred in litigating the appeal, if the prevailing party shows that the position of the opposing party was not substantially justified. The procedures for awarding fees and costs set forth in section 15.474 must be followed in determining the prevailing party's fees and costs except as otherwise provided in this subdivision. For purposes of this subdivision, "costs" means subpoena fees and mileage, transcript costs, court reporter fees, witness fees, postage and delivery costs, photocopying and printing costs, amounts charged the commissioner by the office of administrative hearings, and direct administrative costs of the department; and "substantially justified" means that a position had a reasonable basis in law and fact, based on the totality of the circumstances prior to and during the contested case proceeding and subsequent review.
(b) When an award is made to the department under this subdivision, attorney fees must be calculated at the cost to the department. When an award is made to a provider under this subdivision, attorney fees must be calculated at the rate charged to the provider except that attorney fees awarded must be the lesser of the attorney's normal hourly fee or $100 per hour.
(c) In contested case proceedings involving more than one issue, the administrative law judge shall determine what portion of each party's attorney fees and costs is related to the issue or issues on which it prevailed and for which it is entitled to an award. In making that determination, the administrative law judge shall consider the amount of time spent on each issue, the precedential value of the issue, the complexity of the issue, and other factors deemed appropriate by the administrative law judge.
(d) When the department prevails on an issue involving more than one provider, the administrative law judge shall allocate the total amount of any award for attorney fees and costs among the providers. In determining the allocation, the administrative law judge shall consider each provider's monetary interest in the issue and other factors deemed appropriate by the administrative law judge.
(e) Attorney fees and costs awarded to the department for proceedings under this subdivision must not be reported or treated as allowable costs on the provider's cost report.
(f) Fees and costs awarded to a provider for proceedings under this subdivision must be reimbursed to them within 120 days of the final decision on the award of attorney fees and costs.
(g) If the provider fails to pay the awarded attorney fees and costs within 120 days of the final decision on the award of attorney fees and costs, the department may collect the amount due through any method available to it for the collection of medical assistance overpayments to providers. Interest charges must be assessed on balances outstanding after 120 days of the final decision on the award of attorney fees and costs. The annual interest rate charged must be the rate charged by the commissioner of revenue for late payment of taxes that is in effect on the 121st day after the final decision on the award of attorney fees and costs.
(h) Amounts collected by the commissioner pursuant to this subdivision must be deemed to be recoveries pursuant to section 256.01, subdivision 2, paragraph (o).
(i) This subdivision applies to all contested case proceedings set on for hearing by the commissioner on or after April 29, 1988, regardless of the date the appeal was filed.
Subd. 1f. Legal and related expenses. Legal and related expenses for unresolved challenges to decisions by governmental agencies shall be separately identified and explained on the provider's cost report for each year in which the expenses are incurred. When the challenge is resolved in favor of the governmental agency, the provider shall notify the department of the extent to which its challenge was unsuccessful or the cost report filed for the reporting year in which the challenge was resolved. In addition, the provider shall inform the department of the years in which it claimed legal and related expenses and the amount of the expenses claimed in each year relating to the unsuccessful challenge. The department shall reduce the provider's medical assistance rate in the subsequent rate year by the total amount claimed by the provider for legal and related expenses incurred in an unsuccessful challenge to a decision by a governmental agency.
Subd. 1g. [Repealed, 1997 c 107 s 19]
Subd. 1h. [Repealed, 1997 c 107 s 19]
Subd. 2. [Repealed, 1997 c 107 s 19]
Subd. 3. [Repealed, 2000 c 449 s 15]
1983 c 199 s 15; 1984 c 640 s 32; 1984 c 641 s 21; 1985 c 248 s 69; 1Sp1985 c 3 s 32; 1987 c 403 art 4 s 12; 1988 c 689 art 2 s 163-168; 1990 c 568 art 3 s 78,79; 1991 c 292 art 4 s 63; 1992 c 426 s 1; 1992 c 513 art 7 s 120,121,136; 1Sp1993 c 1 art 5 s 106-108; 1997 c 107 s 9-12; 1999 c 245 art 3 s 30; 2001 c 7 s 51; 2015 c 71 art 6 s 39; 2015 c 78 art 4 s 61; 2016 c 99 art 2 s 9; 2016 c 158 art 1 s 127,128; 2017 c 40 art 1 s 74,75; 1Sp2017 c 6 art 3 s 25
Structure Minnesota Statutes
Chapters 245 - 267 — Public Welfare And Related Activities
Chapter 256B — Medical Assistance For Needy Persons
Section 256B.011 — Policy For Childbirth And Abortion Funding.
Section 256B.02 — Definitions.
Section 256B.021 — Medical Assistance Reform Waiver.
Section 256B.03 — Payments To Vendors.
Section 256B.035 — Managed Care.
Section 256B.037 — Prospective Payment Of Dental Services.
Section 256B.0371 — Performance Benchmarks For Dental Access; Contingent Dental Administrator.
Section 256B.038 — Provider Rate Increases After June 30, 1999.
Section 256B.04 — Duties Of State Agency.
Section 256B.041 — Centralized Disbursement Of Medical Assistance Payments.
Section 256B.042 — Third-party Liability.
Section 256B.043 — Cost-containment Efforts.
Section 256B.05 — Administration By County Agencies.
Section 256B.051 — Housing Stabilization Services.
Section 256B.055 — Eligibility Categories.
Section 256B.056 — Eligibility Requirements For Medical Assistance.
Section 256B.0561 — Periodic Data Matching To Evaluate Continued Eligibility.
Section 256B.057 — Eligibility Requirements For Special Categories.
Section 256B.0571 — Long-term Care Partnership Program.
Section 256B.0575 — Availability Of Income For Institutionalized Persons.
Section 256B.058 — Treatment Of Income Of Institutionalized Spouse.
Section 256B.059 — Treatment Of Assets When A Spouse Is Institutionalized.
Section 256B.0594 — Payment Of Benefits From An Annuity.
Section 256B.0595 — Prohibitions On Transfer; Exceptions.
Section 256B.06 — Eligibility; Migrant Workers; Citizenship.
Section 256B.061 — Eligibility; Retroactive Effect; Restrictions.
Section 256B.0615 — Mental Health Certified Peer Specialist.
Section 256B.0616 — Mental Health Certified Family Peer Specialist.
Section 256B.0621 — Covered Services: Targeted Case Management Services.
Section 256B.0622 — Assertive Community Treatment And Intensive Residential Treatment Services.
Section 256B.0623 — Adult Rehabilitative Mental Health Services Covered.
Section 256B.0624 — Crisis Response Services Covered.
Section 256B.0625 — Covered Services.
Section 256B.0626 — Estimation Of 50th Percentile Of Prevailing Charges.
Section 256B.063 — Cost Sharing.
Section 256B.0631 — Medical Assistance Co-payments.
Section 256B.0635 — Continued Eligibility In Special Circumstances.
Section 256B.0636 — Controlled Substance Prescriptions; Abuse Prevention.
Section 256B.0637 — Presumptive Eligibility; Treatment For Breast Or Cervical Cancer.
Section 256B.0638 — Opioid Prescribing Improvement Program.
Section 256B.064 — Sanctions; Monetary Recovery.
Section 256B.0641 — Recovery Of Overpayments.
Section 256B.0642 — Federal Financial Participation.
Section 256B.0643 — Vendor Request For Contested Case Proceeding.
Section 256B.0644 — Reimbursement Under Other State Health Care Programs.
Section 256B.0646 — Minnesota Restricted Recipient Program; Personal Care Assistance Services.
Section 256B.065 — Social Security Amendments.
Section 256B.0651 — Home Care Services.
Section 256B.0652 — Authorization And Review Of Home Care Services.
Section 256B.0653 — Home Health Agency Services.
Section 256B.0654 — Home Care Nursing.
Section 256B.0658 — Housing Access Grants.
Section 256B.0659 — Personal Care Assistance Program.
Section 256B.0671 — Covered Mental Health Services.
Section 256B.0711 — Quality Self-directed Services Workforce.
Section 256B.072 — Performance Reporting And Quality Improvement System.
Section 256B.073 — Electronic Visit Verification.
Section 256B.075 — Disease Management Programs.
Section 256B.0751 — Health Care Homes.
Section 256B.0753 — Payment Restructuring; Care Coordination Payments.
Section 256B.0754 — Payment Reform.
Section 256B.0755 — Integrated Health Partnership Demonstration Project.
Section 256B.0756 — Hennepin And Ramsey Counties Pilot Program.
Section 256B.0757 — Coordinated Care Through A Health Home.
Section 256B.0758 — Health Care Delivery Pilot Program.
Section 256B.0759 — Substance Use Disorder Demonstration Project.
Section 256B.076 — Case Management Services.
Section 256B.08 — Application.
Section 256B.09 — Investigations.
Section 256B.0911 — Long-term Care Consultation Services.
Section 256B.0913 — Alternative Care Program.
Section 256B.0914 — Conflicts Of Interest Related To Medicaid Expenditures.
Section 256B.0916 — Expansion Of Home And Community-based Services.
Section 256B.0917 — Home And Community-based Services For Older Adults.
Section 256B.0918 — Employee Scholarship Costs.
Section 256B.0919 — Adult Foster Care And Family Adult Day Care.
Section 256B.092 — Services For Persons With Developmental Disabilities.
Section 256B.0921 — Home And Community-based Services Innovation Pool.
Section 256B.0922 — Essential Community Supports.
Section 256B.0924 — Targeted Case Management Services.
Section 256B.0926 — Admission Review Team; Intermediate Care Facilities.
Section 256B.093 — Services For Persons With Traumatic Brain Injuries.
Section 256B.094 — Child Welfare Targeted Case Management Services.
Section 256B.0943 — Children's Therapeutic Services And Supports.
Section 256B.0945 — Services For Children With Severe Emotional Disturbance.
Section 256B.0946 — Children's Intensive Behavioral Health Services.
Section 256B.0947 — Intensive Rehabilitative Mental Health Services.
Section 256B.0948 — Foster Care Rate Limits.
Section 256B.0949 — Early Intensive Developmental And Behavioral Intervention Benefit.
Section 256B.095 — Quality Assurance System Established.
Section 256B.0951 — Quality Assurance Commission.
Section 256B.0952 — County Duties; Quality Assurance Teams.
Section 256B.0953 — Quality Assurance Process.
Section 256B.0954 — Certain Persons Defined As Mandated Reporters.
Section 256B.0955 — Duties Of The Commissioner Of Human Services.
Section 256B.097 — Regional And Systems Improvement For Minnesotans Who Have Disabilities.
Section 256B.12 — Legal Representation.
Section 256B.121 — Treble Damages.
Section 256B.14 — Relative's Responsibility.
Section 256B.15 — Claims Against Estates.
Section 256B.17 — Transfers Of Property.
Section 256B.18 — Methods Of Administration.
Section 256B.19 — Division Of Cost.
Section 256B.194 — Federal Payments.
Section 256B.196 — Intergovernmental Transfers; Hospital And Physician Payments.
Section 256B.197 — Intergovernmental Transfers; Inpatient Hospital Payments.
Section 256B.1973 — Directed Payment Arrangements.
Section 256B.198 — Payments For Non-hospital-based Governmental Health Centers.
Section 256B.199 — Payments Reported By Governmental Entities.
Section 256B.20 — County Appropriations.
Section 256B.21 — Change Of Residence.
Section 256B.22 — Compliance With Social Security Act.
Section 256B.23 — Use Of Federal Funds.
Section 256B.24 — Prohibitions.
Section 256B.25 — Payments To Certified Facilities.
Section 256B.26 — Agreements With Other State Departments.
Section 256B.27 — Medical Assistance; Cost Reports.
Section 256B.30 — Health Care Facility Report.
Section 256B.32 — Facility Fee Payment.
Section 256B.35 — Personal Needs Allowance; Persons In Certain Facilities.
Section 256B.36 — Special Personal Allowance For Certain Individuals.
Section 256B.37 — Private Insurance Policies, Causes Of Action.
Section 256B.39 — Avoidance Of Duplicate Payments.
Section 256B.40 — Subsidy For Abortions Prohibited.
Section 256B.421 — Definitions.
Section 256B.431 — Rate Determination.
Section 256B.434 — Payment Rates And Procedures; Contracts And Agreements.
Section 256B.439 — Long-term Care Quality Profiles.
Section 256B.48 — Conditions For Participation.
Section 256B.49 — Home And Community-based Service Waivers For Persons With Disabilities.
Section 256B.4905 — Home And Community-based Services Policy Statement.
Section 256B.4911 — Consumer-directed Community Supports.
Section 256B.4912 — Home And Community-based Waivers; Providers And Payment.
Section 256B.4914 — Home And Community-based Services Waivers; Rate Setting.
Section 256B.492 — Home And Community-based Settings For People With Disabilities.
Section 256B.493 — Adult Foster Care Planned Closure.
Section 256B.501 — Rates For Community-based Services For Persons With Disabilities.
Section 256B.5011 — Icf/dd Reimbursement System Effective October 1, 2000.
Section 256B.5012 — Icf/dd Payment System Implementation.
Section 256B.5013 — Payment Rate Adjustments.
Section 256B.5014 — Reporting Requirements.
Section 256B.5015 — Pass-through Of Other Services Costs.
Section 256B.51 — Nursing Homes; Cost Of Home Care.
Section 256B.69 — Prepaid Health Plans.
Section 256B.6903 — Ombudsperson For Managed Care.
Section 256B.691 — Risk-based Transportation Payments.
Section 256B.692 — County-based Purchasing.
Section 256B.6925 — Enrollee Information.
Section 256B.6926 — State Monitoring.
Section 256B.6927 — Quality Assessment And Performance.
Section 256B.6928 — Managed Care Rates And Payments.
Section 256B.693 — State-operated Services; Managed Care.
Section 256B.694 — Sole-source Or Single-plan Managed Care Contract.
Section 256B.70 — Demonstration Project Waiver.
Section 256B.71 — Social Health Maintenance Organization Demonstration.
Section 256B.72 — Commissioner's Recovery Of Overpayments.
Section 256B.73 — Demonstration Project For Uninsured Low-income Persons.
Section 256B.74 — Special Payments.
Section 256B.75 — Hospital Outpatient Reimbursement.
Section 256B.756 — Reimbursement Rates For Births.
Section 256B.758 — Reimbursement For Doula Services.
Section 256B.76 — Physician And Dental Reimbursement.
Section 256B.761 — Reimbursement For Mental Health Services.
Section 256B.762 — Reimbursement For Health Care Services.
Section 256B.763 — Critical Access Mental Health Rate Increase.
Section 256B.7635 — Reimbursement For Evidence-based Public Health Nurse Home Visits.
Section 256B.764 — Reimbursement For Family Planning Services.
Section 256B.765 — Provider Rate Increases.
Section 256B.766 — Reimbursement For Basic Care Services.
Section 256B.767 — Medicare Payment Limit.
Section 256B.77 — Coordinated Service Delivery System For Persons With Disabilities.
Section 256B.771 — Complementary And Alternative Medicine Demonstration Project.
Section 256B.78 — Demonstration Project For Family Planning Services.
Section 256B.79 — Integrated Care For High-risk Pregnant Women.
Section 256B.795 — Maternal And Infant Health Report.
Section 256B.81 — Mental Health Provider Appeal Process.
Section 256B.82 — Prepaid Plans And Mental Health Rehabilitative Services.
Section 256B.84 — American Indian Contracting Provisions.
Section 256B.85 — Community First Services And Supports.
Section 256B.851 — Community First Services And Supports; Payment Rates.