A. All providers enrolled with the Department may appeal any action by the Department or its contractor that is subject to appeal under the Administrative Process Act (§ 2.2-4000 et seq.). For provider appeals stemming from an action taken by a Department contractor, including managed care organizations, the provider shall exhaust the contractor's internal reconsideration and internal appeal processes, if any, before appealing to the Department.
B. The Department shall make an initial appeal determination in accordance with the state plan for medical assistance, the provisions of § 2.2-4019, and applicable federal law. The initial determination shall be issued within 180 days of the receipt of the appeal request. If the agency does not render a decision within 180 days, or, in the case of a joint agreement to stay the appeal decision pursuant to subsection D, within the time after the stay expires and before the appeal timeframe resumes, the decision is deemed to be in favor of the provider.
C. An appeal of the Department's initial determination concerning provider reimbursement shall be heard in accordance with § 2.2-4020 of the Administrative Process Act (§ 2.2-4020 et seq.) and the state plan for medical assistance provided for in § 32.1-325. The hearing officer appointed pursuant to § 2.2-4024 shall conduct the appeal and submit a recommended decision to the Director within 120 days of the agency's receipt of the appeal request, unless the settlement provisions of this section apply. The Director shall consider the parties' exceptions and issue the final agency case decision within 60 days of receipt of the hearing officer's recommended decision. If the Director does not render a final agency case decision within 60 days of the receipt of the hearing officer's recommended decision, the decision is deemed to be in favor of the provider. The Director shall adopt the hearing officer's recommended decision unless to do so would be an error of law or Department policy. Any final agency case decision in which the Director rejects a hearing officer's recommended decision shall state with particularity the basis for rejection. Prior to a final agency case decision issued in accordance with § 2.2-4023, the Director may not undertake recovery of any overpayment amount paid to the provider through offset or other means. Once a final determination of overpayment has been made, the Director shall undertake full recovery of such overpayment whether or not the provider disputes, in whole or in part, the initial or the final determination of overpayment. Interest charges on the unpaid balance of any overpayment shall accrue pursuant to § 32.1-313 from the date the Department's determination becomes final. Nothing in § 32.1-313 shall be construed to require interest payments on any portion of overpayment other than the unpaid balance referenced herein.
D. The Department and the provider may jointly agree to stay the deadline for the informal appeal decision or for the formal appeal recommended decision of the hearing officer for a period of up to 60 days to facilitate settlement discussions. If the parties reach a resolution as reflected by a written settlement agreement within the 60-day period, then the stay shall be extended for such additional time as may be necessary for review and approval of the settlement agreement in accordance with § 2.2-514.
E. The burden of proof in informal and formal administrative appeals is on the provider. If an action stems from a Department contractor, then such contractor shall represent itself during the informal and formal appeal proceedings. No such contractor, including managed care organizations, shall have the right to file a petition for reconsideration or an appeal for court review of the Department's final agency decision.
F. The agency shall reimburse a provider for reasonable and necessary attorney fees and costs associated with an informal or formal administrative appeal if the provider substantially prevails on the merits of the appeal and the agency's position is not substantially justified, unless special circumstances would make an award unjust. In any case in which a provider has recovered attorney fees and costs associated with an informal or formal administrative appeal, the provider shall not be entitled to recover those same attorney fees and costs in a subsequent judicial proceeding.
G. Court review of final agency determinations concerning provider reimbursement shall be made in accordance with the Administrative Process Act (§ 2.2-4000 et seq.). In any case in which a final determination of overpayment has been reversed in a subsequent judicial proceeding, the provider shall be reimbursed that portion of the payment to which he is entitled plus any applicable interest, within 30 days of the subsequent judicial order.
1986, c. 441; 2000, c. 967; 2025, cc. 621, 651.
Notes of Decisions
Finnerty v. Thornton Hall, Inc., 593 S.E.2d 568 (Va. Ct. App. 2004).
· cites it 29× “The Director first argues that the trial court erred by “failing to consider DMAS’s expertise and specialized competence in interpreting its own statutes and regulations.”
Child.'s Hosp. of the King's Daughters, Inc. v. Price, 258 F. Supp. 3d 672 (E.D. Va. 2017).
· cites it 9× “at 14; Va. Code § 32.1-325.1 (“In any case in which a final determination of overpayment has been reversed in a subsequent judicial proceeding, the provider shall be reimbursed that portion of the payment to which he is entitled plus any applicable interest, within thirty days…”
Smith v. Liberty Nursing Home, Inc., 522 S.E.2d 890 (Va. Ct. App. 2000).
· cites it 10× “After the payments had been made by DMAS and pursuant to Code § 32.1-325.1, the Director made “initial determinations” between October 3, 1990 and July 15, 1992, that DMAS had overpaid the appellees $968,875 for excessive depreciation and lease cost reimbursements for the Rose…”
Psychiatric Solutions of Virginia, Inc. v. Finnerty, 676 S.E.2d 358 (Va. Ct. App. 2009).
· cites it 6× “In executing the Provider Agreement, Whisper Ridge has been put on notice of the provision in Va.Code § 32.1-325.1(B) that any proceedings, administrative or judicial, are controlled by the Administrative Process Act.”
Dep't OF MED. v. Beverly Healthcare, 601 S.E.2d 604 (Va. 2004).
· cites it 2× “" Code § 32.1-325.1(B). The rate of reimbursement for a provider is determined, in part, by its location in a particular geographic region or "peer group" within the Commonwealth.”
Fam. Redirection Inst., Inc. v. Commonwealth of Virginia, etc., 739 S.E.2d 916 (Va. Ct. App. 2013).
· cites it 2× “See Code § 32.1-325.1(C). After considering the evidence in the administrative record, DMAS concluded in the final agency decision that FRI did not prove by a preponderance of the evidence that its employees were properly qualified as QMHPs.”
Dep't of Med. Assistance Servs. v. Beverly Healthcare, 585 S.E.2d 858 (Va. Ct. App. 2003).
· cites it 2× “” Code § 32.1-325.1(B). To control costs, DMAS has instituted cost ceiling limitations, or caps, on the reimbursement of certain costs incurred by nursing facilities in providing service to Medicaid patients.”
Culpeper Reg'l Hosp. v. Cynthia B. Jones, Dir., 767 S.E.2d 236 (Va. Ct. App. 2015).
· cites it 2× “The Hospital eventually sought a formal appeal hearing pursuant to Code § 32.1-325.1. The Hospital withdrew its appeal for two of the patients at issue, leaving an amount in controversy of approximately $36,000.”
Beverly Health & Rehab. Servs., Inc. v. Metcalf, 484 S.E.2d 156 (Va. Ct. App. 1997).
· cites it 2× “See Code § 32.1-325.1. Federal regulations require DMAS to: provide an appeals or exception procedure that allows individual providers an opportunity to submit additional evidence and receive prompt administrative review, with respect to such issues as the agency determines…”
— Va. Code Ann. § 32.1-325.1(A) — 2 cases
Finnerty v. Thornton Hall, Inc., 593 S.E.2d 568 (Va. Ct. App. 2004).
“The Director first argues that the trial court erred by “failing to consider DMAS’s expertise and specialized competence in interpreting its own statutes and regulations.”
Child.'s Hosp. of the King's Daughters, Inc. v. Price, 258 F. Supp. 3d 672 (E.D. Va. 2017).
“at 14; Va. Code § 32.1-325.1 (“In any case in which a final determination of overpayment has been reversed in a subsequent judicial proceeding, the provider shall be reimbursed that portion of the payment to which he is entitled plus any applicable interest, within thirty days…”
— Va. Code Ann. § 32.1-325.1(B) — 12 cases
Finnerty v. Thornton Hall, Inc., 593 S.E.2d 568 (Va. Ct. App. 2004).
“The Director first argues that the trial court erred by “failing to consider DMAS’s expertise and specialized competence in interpreting its own statutes and regulations.”
Psychiatric Solutions of Virginia, Inc. v. Finnerty, 676 S.E.2d 358 (Va. Ct. App. 2009).
“In executing the Provider Agreement, Whisper Ridge has been put on notice of the provision in Va.Code § 32.1-325.1(B) that any proceedings, administrative or judicial, are controlled by the Administrative Process Act.”
Dep't OF MED. v. Beverly Healthcare, 601 S.E.2d 604 (Va. 2004).
“" Code § 32.1-325.1(B). The rate of reimbursement for a provider is determined, in part, by its location in a particular geographic region or "peer group" within the Commonwealth.”
Dep't of Med. Assistance Servs. v. Beverly Healthcare, 585 S.E.2d 858 (Va. Ct. App. 2003).
“” Code § 32.1-325.1(B). To control costs, DMAS has instituted cost ceiling limitations, or caps, on the reimbursement of certain costs incurred by nursing facilities in providing service to Medicaid patients.”
— Va. Code Ann. § 32.1-325.1(C) — 1 case
Fam. Redirection Inst., Inc. v. Commonwealth of Virginia, etc., 739 S.E.2d 916 (Va. Ct. App. 2013).
“See Code § 32.1-325.1(C). After considering the evidence in the administrative record, DMAS concluded in the final agency decision that FRI did not prove by a preponderance of the evidence that its employees were properly qualified as QMHPs.”
Annotations are extracted automatically from the opinions in the
Syfert caselaw corpus and ranked by authority, recency, and
treatment. Dots show Syfertize treatment of the citing case itself.