Administrative Hearings and Appeals

Lavette Young
Phone (919) 647- 8200
Fax (919) 715- 6394

The Department of Health and Human Services Hearing Office (DHHS Hearings Office) conducts recipient appeals for any denial, termination, suspension or reduction of Medicaid covered services.

Recipient appeals are also held for prior approval requests for certain Medicaid covered medical services, including certain surgical procedures (e.g., breast reduction, gastric bypass, etc.); outpatient specialized therapies such as physical, occupational, and speech therapy; out-of-state medical treatment; and other specific services (e.g., private duty nursing, Community Alternatives Program for Children, and Intermediate Level of Care for the Mentally Retarded. The Hearing Office is also responsible for holding appeals regarding prior approval for certain prescription drugs.

Other types of recipient appeals condcted by the Hearing Office include appeals regarding a change in level of care for recipients in the Community Alternatives Program for Diabled Adults.

The Hearing Office also handles appeals from providers (e.g., hospitals, physicians, pharmacies, home health agencies, etc.) of recoupments sought by Program Integrity based on post-payment reviews; psychiatric facility admission prior approvals and length of stay approvals.

All of the aforementioned appeals are "informal" appeals as provided by NCGS 150B-22.

The Hearing Office also conducts more formal appeals of four types: 1) appeals regarding the transfer/discharge of residents from nursing facilities, 2) appeals regarding the transfer/discharge of residents from adult care homes, 3) appeals of PASARR decisions and 4) appeals of Carolina Access contract terminations. The residents appealing transfer/discharge notices need not be recipients of Medicaid.

Updated February 15, 2008