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Chapter 350-1 ADMINISTRATION

Rule 350-1-.01 Definitions

(1) "Act" means the Georgia Medical Assistance Act of 1977; O.C.G.A. Title 49, Article 7.
(2) "Administrative Review" means the formal reconsideration, as a result of the proper and timely submission of a provider's request therefor, by any Departmental Division, Office, or Unit which has proposed an adverse action which will aggrieve a party if it is carried out.
(3) "Adverse Action" means an instance in which the Department:
(a) denies or reduces the amount of reimbursement claimed by a provider;
(b) recovers funds previously paid to a provider, other than through lawsuit;
(c) sets or changes a provider's reimbursement rate;
(d) withholds reimbursement from a provider;
(e) denies payment for future admissions to a nursing facility, except as provided in Chapter 350-3 of these Rules;
(f) suspends, terminates, or refuses to enroll, re-enroll, or reinstate a provider or prospective provider; or
(g) performs any other act which aggrieves a provider.
(4) "Aggrieved" means to have received notice of a loss or injury in fact to an interest within the zone of interests protected by a law or regulation governing Medical Assistance.
(5) "Applicant for medical assistance" means a person who has made application for certification as being eligible, generally, to have medical assistance paid in his/her behalf pursuant to the terms of the State Plan and whose application has not been acted upon favorably.
(6) "Board" means the Board of Medical Assistance.
(7) "Business day" means day on which the Department is officially open to conduct its affairs.
(8) "Commissioner" means the Commissioner of Medical Assistance.
(9) "Department" means the Department of Medical Assistance.
(10) "Hearing" means a formal proceeding before an Administrative Law Judge in which parties affected by an action or an intended action of the Department shall be allowed to present testimony, documentary evidence, and argument as to why such action should or should not be taken.
(11) "Administrative Law Judge (ALJ)" means a member of the State Bar of Georgia authorized by the Commissioner to administer the hearing provisions of the medical assistance program as set out in O.C.G.A. § 49-4-153.
(12) "Medical Assistance" means payment to a provider of a part of or all of the cost of certain items of medical or remedial care or services rendered by a provider to a recipient of medical assistance, provided such items are rendered and received in accordance with such provisions of Title XIX of the federal Social Security Act of 1935, as amended, regulations promulgated pursuant thereto by the Secretary of Health and Human Services, all applicable laws of the State of Georgia, the State Plan, and regulations of the Department which are in effect on the date on which the care or services are rendered.
(13) "Notice of hearing" means
(a) for the purpose of rule-making, a written statement of the substance of a proposed rule which will afford notice to all interested persons, such notice being given by mail or by publication at least thirty (30) days prior to the date of hearing; provided, however, that when the Board finds it necessary under Rule 350-2-.04, such notice may be shortened or eliminated; and
(b) for the purpose of contested cases, a written statement issued pursuant to Chapter 350-4 of these Rules by an Administrative Law Judge appointed to preside over a hearing.
(14) "Party" means any person against whom the Department has taken an adverse action and who has been approved to participate in a hearing by the Department or by the presiding Administrative Law Judge.
(15) "Person" means any individual, partnership, corporation, or other entity recognized under Georgia law.
(16) "Pleadings" consist of the notice of adverse action issued by the Department which aggrieves the provider, the provider's Request for hearing requesting review of the adverse action, and any amendments to such documents.
(17) "Program" means all of the functions of the Georgia Department of Medical Assistance.
(18) "Provider of medical assistance" means a person or institution, public or private, which possesses all licenses, permits, certificates, approvals, registrations, charters, and other forms of permission issued by entities other than the Department, which forms of permission are required by law either to render care or to receive medical assistance in which federal financial participation is available, which meets the further requirements for participation prescribed by the Department, and which is enrolled, in the manner and according to the terms prescribed by the Department, to participate in the State Plan.
(19) "Reasonable time" means such time as is appropriate to do what is required to be done, as soon as circumstances will permit; any time which is not manifestly unreasonable may be fixed by agreement of the parties, and what is reasonable depends on the nature, purpose, and circumstances of each case.
(20) "Recipient of medical assistance" means a person who has been certified eligible, pursuant to the terms of the State Plan, to have medical assistance paid in his/her behalf.
(21) "Request for Hearing" is a written document submitted to the Department seeking formal redress of an action by the Department which aggrieves the person making the request. To be effective, a request for Hearing must comply with the provisions of Rule 350-4-.05.
(22) "Rule" means each Department regulation or written statement of general or particular applicability which implements law governing the Department's organization or its administration of the State Plan pursuant to the authority granted under O.C.G.A., § 49-4-142, et seq., as amended; provided, however, that the amount, duration, scope, and terms and conditions of eligibility for and receipt of medical assistance, statements of general or specific policy and interpretations thereof, informational notices, contracts, and policy and procedure manuals and amendments thereto, are specifically excluded.
(23) "State Plan" means all documentation submitted by the Commissioner, on behalf of the Department, to and for approval by the Secretary of Health and Human Services pursuant to Title XIX of the federal Social Security Act of 1935, as amended.
(24) Time Computed. The computation of any period of time referred to in these Rules shall begin with the first day following that on which the act initiating such period of time occurs. When the last day of the period so computed is a day on which the Department is closed, the period shall run until the end of the next business day.
(25) All petitions, requests, notices, and decisions referred to in these Rules must be in writing.

Rule 350-1-.02 Department of Medical Assistance

(1) The Department of Medical Assistance was created by the General Assembly in 1977. The Department is authorized to:
(a) adopt and administer a State Plan for medical assistance as defined in paragraph (23) of Rule 350-1-.01, provided such State Plan is administered within the appropriations made available to the Department;
(b) establish the amount, duration, scope, and terms and conditions of eligibility for and receipt of such medical assistance as it may elect to authorize pursuant to Article 7, Title 49 of the Official Code of Georgia Annotated;
(c) establish such rules and regulations as may be necessary or desirable to execute the State Plan and to receive the maximum amount of federal financial participation available in expenditures made pursuant to the State Plan;
(d) enter into such reciprocal and cooperative arrangements with other states, persons, and institutions, public and private, as it may deem necessary or desirable in order to execute the State Plan.
(2) The Department shall administer the State Plan for Medical Assistance in accordance with these Rules.
(3) The Department shall publish the terms and conditions for receipt of medical assistance in Policies and Procedures Manuals for each of the categories of service authorized under the State Plan. A copy of the Manual for each category of service shall be disseminated to each provider enrolled for that category and to each prospective provider seeking to enroll for that category. Such manuals shall be amended from time to time when the Department finds it necessary or appropriate to do so. All such amendments shall be disseminated to affected providers at the addresses at which they are then registered with the Department. Amended provisions shall be effective as specified by the Department at the time of dissemination. Each Manual shall specify, at a minimum, the following:
(a) conditions of participation;
(b) recordkeeping, claims submission, and payment requirements;
(c) requirements for prior approval of services;
(d) scope of services;
(e) reimbursement methodology;
(f) adverse actions the Department may take against a provider and the circumstances under which such actions may be taken; and
(g) administrative review and hearing rights available to a provider.

Rule 350-1-.03 Commissioner of Medical Assistance

The Commissioner of Medical Assistance shall be the chief administrative officer of the Department and, subject to the general policy established by the Board, shall supervise, direct, account for, organize, plan, administer, and execute the functions vested in the Department.

Rule 350-1-.04 Board of Medical Assistance

The Board of Medical Assistance is empowered to establish the general policy to be followed by the Department.

(a) The Board is composed of five (5) persons appointed by the Governor and confirmed by the Senate.
(b) The presiding officer of the Board shall be its Chairperson, who shall be selected by the board and serve as such at the pleasure of the Board.
(c) A quorum shall consist of a majority of its members.
(d) The Governor shall appoint Board members to four-year terms of office.
(e) Vacancies in office shall be filled by the appointment of the Governor and said appointments shall be submitted to the Senate for confirmation at the next session of the General Assembly. An appointment to fill a vacancy, other than a vacancy created by the expiration of a term of office, shall be for the balance of the unexpired term of the Board member succeeded.
(f) Board members, if eligible therefor, shall receive per diem and expenses commensurate with the amounts established by O.C.G.A. § 45-7-21.

Rule 350-1-.05 Practice of Non-Discrimination

In accordance with Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973, no individual shall be excluded from participation, or be denied benefits, or be subjected to any other form of discrimination by the Department or providers of medical assistance, by reason of handicap, race, color, sex, age, religion, or national origin.