C.R.S. Section 25.5-4-207
Appeals

  • rules
  • applicability

(1)(a)(I) If an application for medical assistance is not acted upon within a reasonable time after filing of the same, or if an application is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or modified, the applicant or recipient, as the case may be, may appeal to the state department in the manner and form prescribed by the rules of the state department. Except as permitted under federal law, state department rules must provide for at least a ten-day advance notice before the effective date of any suspension, termination, or modification of medical assistance. The county or designated service agency shall notify the applicant or recipient in writing of the basis for the county’s decision or action and shall inform the applicant or recipient of the right to a county or service agency conference under the dispute resolution process described in paragraph (b) of this subsection (1) and of the right to a state-level appeal and the process for appeal.

(II)

The applicant or recipient has sixty days after the date of the notice to file an appeal. If the recipient files an appeal prior to the effective date of the intended action, existing medical assistance benefits must automatically continue unchanged until the appeal process is completed, unless the recipient requests in writing that medical assistance benefits not continue during the appeal process; except that, to the extent authorized by federal law, the state department rules may permit existing medical assistance benefits to continue until the appeal process is completed even if the recipient’s appeal is filed after the effective date of the intended action. The state department shall promulgate rules consistent with federal law that prescribe the circumstances under which the county or designated service agency may continue benefits if an appeal is filed after the effective date of the intended action. At a minimum, the rules must allow for continuing benefits when the recipient’s health or safety is impacted, the recipient was not able to timely respond due to the recipient’s disability or employment, the recipient’s caregiver was unavailable due to the caregiver’s health or employment, or the recipient did not receive the county’s or designated service agency’s notice prior to the effective date of the intended action.

(III)

Either prior to appeal or as part of the filing of an appeal, the applicant or recipient may request the dispute resolution process described in paragraph (b) of this subsection (1) through the county department or service delivery agency.

(b)

Every county department or service delivery agency shall adopt procedures for the resolution of disputes arising between the county department or the service delivery agency and any applicant for or recipient of medical assistance. Such procedures are referred to in this section as the “dispute resolution process”. Two or more counties may jointly establish the dispute resolution process. The dispute resolution process must be consistent with rules promulgated by the state board pursuant to article 4 of title 24, C.R.S. The dispute resolution process shall include an opportunity for all clients to have a county conference, upon the client’s request, and such requirement may be met through a telephonic conference upon the agreement of the client and the county department. The dispute resolution process need not conform to the requirements of section 24-4-105, C.R.S., as long as the rules adopted by the state board include provisions specifically setting forth expeditious time frames, notice, and an opportunity to be heard and to present information. If the dispute is resolved through the county or service delivery agency’s dispute resolution process and the applicant or recipient has already filed an appeal, the county shall inform the applicant or recipient of the process for dismissing the appeal.

(c)

The state board shall adopt rules setting forth what other issues, if any, may be appealed by an applicant or recipient to the state department. A hearing need not be granted when either state or federal law requires or results in a reduction or deletion of a medical assistance benefit unless the applicant or recipient is arguing that his or her case does not fit within the parameters set forth by the change in the law. In notifying the applicant or recipient that an appeal is being denied because of a change in state or federal law, the state’s notice must inform the applicant or recipient that further appeal should be directed to the appropriate state or federal court.

(d)

Upon receipt of an appeal, the office of administrative courts shall give the appellant at least ten days’ notice of the hearing date and an opportunity for a fair hearing in accordance with the rules of the state department. The fair hearing must comply with section 24-4-105, C.R.S., and the state department’s administrative law judge shall preside.

(d.5)

Intentionally left blank —Ed.

(I)

At the commencement of a hearing that concerns the termination or reduction of an existing benefit, the state department’s administrative law judge shall review the legal sufficiency of the notice of action from which the recipient is appealing. If the administrative law judge determines that the notice is legally insufficient, the administrative law judge shall inform the appellant that the termination or reduction may be set aside on the basis of insufficient notice without proceeding to a hearing on the merits. The appellant may affirmatively waive the defense of insufficient notice and agree to proceed with a hearing on the merits or may ask the administrative law judge to decide the appeal on the basis of his or her finding that the notice is legally insufficient. The administrative law judge shall also inform the appellant that the state department may issue legally sufficient notice in the future and that the state department may seek recoupment of benefits if a basis for denial or reduction of benefits is subsequently determined.

(II)

This subsection (1)(d.5) applies to hearings conducted on and after January 1, 2018.

(e)

The appellant shall have an opportunity to examine all applications and pertinent records concerning the appellant that constitute a basis for the denial, suspension, termination, or modification of medical assistance benefits. The person or persons involved in the decision denying, suspending, terminating, or modifying medical assistance benefits or, if the person or persons are not reasonably available, a person familiar with the facts underlying the basis for the decision, shall be available for cross-examination if requested by the appellant.

(2)

All decisions of the state department shall be binding upon the county department involved and shall be complied with by such county department.

Source: Section 25.5-4-207 — Appeals - rules - applicability, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5‑4‑101
Short title
25.5‑4‑102
Legislative declaration
25.5‑4‑103
Definitions
25.5‑4‑104
Program of medical assistance - single state agency
25.5‑4‑105
Federal requirements under Title XIX
25.5‑4‑106
Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services
25.5‑4‑107
Retaliation definition
25.5‑4‑201
Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules
25.5‑4‑203
Advisory council established
25.5‑4‑204
Automated medical assistance administration
25.5‑4‑205
Application - verification of eligibility - demonstration project - rules - repeal
25.5‑4‑205.5
Confined persons - suspension of benefits
25.5‑4‑206
Reimbursement to counties - costs of administration
25.5‑4‑207
Appeals - rules - applicability
25.5‑4‑208
County duties - transitional medicaid
25.5‑4‑209
Payments by third parties - copayments by recipients - review - appeal - children’s waiting list reduction fund - rules - repeal
25.5‑4‑210
Purchase of health insurance for recipients
25.5‑4‑211
Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year
25.5‑4‑212
Medicaid client correspondence improvement process - legislative declaration - definition
25.5‑4‑213
Audit of medicaid client correspondence - definition
25.5‑4‑215
Study - benefits for persons on work release - repeal
25.5‑4‑216
Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal
25.5‑4‑300.4
Last resort for payment - legislative intent
25.5‑4‑300.7
Prevention of coding errors - prepayment review of claims
25.5‑4‑300.9
Explanation of benefits - medicaid recipients - legislative declaration
25.5‑4‑301
Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - repeal
25.5‑4‑302
Recovery of assets
25.5‑4‑303
State income tax refund intercept - garnishment of earning - failure to provide medical support for child
25.5‑4‑303.3
Provider fraud - attorney general report
25.5‑4‑303.5
Short title
25.5‑4‑304
Definitions
25.5‑4‑305
False medicaid claims - liability for certain acts
25.5‑4‑306
Civil actions for false medicaid claims
25.5‑4‑307
False medicaid claims procedures - statute of limitations
25.5‑4‑308
False medicaid claims jurisdiction
25.5‑4‑309
False medicaid claims civil investigation demands
25.5‑4‑310
Medicaid false claims report
25.5‑4‑401
Providers - payments - rules
25.5‑4‑401.2
Performance-based payments - reporting - repeal
25.5‑4‑401.5
Review of provider rates - advisory committee - recommendations - repeal
25.5‑4‑402
Providers - hospital reimbursement - hospital review program - rules
25.5‑4‑402.4
Hospitals - healthcare affordability and sustainability fee - legislative declaration - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - rules - reports - repeal
25.5‑4‑402.5
Providers - state university teaching hospitals
25.5‑4‑402.8
Hospital transparency report - definitions
25.5‑4‑403
Providers - behavioral health safety net providers - reimbursement
25.5‑4‑403.1
Providers - community mental health centers - cost reporting
25.5‑4‑404
Payments for clinic services - restrictions on use
25.5‑4‑405
Mental health managed care service providers - requirements
25.5‑4‑406
Rate setting - medicaid residential treatment service providers - monitoring and auditing - report
25.5‑4‑407
Services by licensed psychologists without a doctor’s referral
25.5‑4‑408
Services provided by licensed psychologists - cost containment program
25.5‑4‑409
Authorization of services - nurse anesthetists - advanced practice registered nurses
25.5‑4‑410
Services of audiologists and speech pathologists without supervision
25.5‑4‑411
Authorization of services provided by dental hygienists
25.5‑4‑412
Family planning services - family-planning-related services - rules - definitions
25.5‑4‑413
Certain providers to inform patients of rights concerning advance medical directives
25.5‑4‑414
Providers - physicians - prohibition of certain referrals - definitions
25.5‑4‑415
No public funds for abortion - exception - definitions - repeal
25.5‑4‑416
Providers - medical equipment and supplies - requirements
25.5‑4‑417
Provider fee - medicaid providers - state plan amendment - rules - definitions
25.5‑4‑420
Providers to obtain unique NPI - service site - provider type - definitions
25.5‑4‑422
Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules
25.5‑4‑423
Targets for investments in primary care
25.5‑4‑425
Providers - health-care services related to labor and delivery - reimbursement
25.5‑4‑427
Supplemental state payment to the Denver health and hospital authority - repeal
25.5‑4‑428
Prior authorization for a step-therapy exception - rules - definition
25.5‑4‑429
Hospital and provider billing requirements - description of service provided - rules
25.5‑4‑430
Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates
25.5‑4‑503
Waiver applications - authorization
25.5‑4‑505
Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal
25.5‑4‑506
Coverage for doula services - stakeholder process - federal authorization - scholarship program - training - report - definitions - repeal
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-4-207’s source at colorado​.gov