Sec. 10.09.10.34. Appeal Procedures

A. Except as provided for in §B of this regulation, providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.

B. Nursing Home Appeal Board.

(1) Appeals regarding rate calculations or cost report adjustments which cannot be resolved administratively go to the Nursing Home Appeal Board.

(2) The Appeal Board shall be composed of the following members:

(a) A representative of the nursing home industry who is:

(i) Knowledgeable in Medicare and Medicaid reimbursement principles; and

(ii) Appointed by the Secretary;

(b) An individual who:

(i) Is employed by the State;

(ii) Knowledgeable in Medicare and Medicaid reimbursement principles;

(iii) Did not directly participate in the field verification or desk review; and

(iv) Is appointed by the Secretary; and

(c) A third member selected by the first two members of the Board.

(3) When the Board is reviewing an appeal from a provider in which a Board member is employed or in which he has a financial or personal interest, the Secretary shall designate an alternate for that member.

(4) If the provider elects to appeal to the Appeal Board and the Appeal Board finds in favor of the provider, the Department shall initiate a claims adjustment settlement for the impacted service dates within 60 days after the notification of the findings.

(5) The Department or any provider aggrieved by a reimbursement decision of the Appeal Board may not appeal to the Board of Review but may take a direct judicial appeal. The appeal shall be made as provided for judicial review of final decisions in the Administrative Procedure Act, §10-222, State Government Article, Annotated Code of Maryland.

(6) An appeal shall be filed in accordance with COMAR 10.01.09.