Article 12 Section 01 Policy

 

Table of Contents

Title

PG Cite

General

12.01.01A

Scope of Services and Payment Issues

12.01.01B

Eligibility Determination

12.01.01C

Hearing Officer

12.01.01D

   

 

12.01.01 Policy

 

12.01.01A
General

An appeal process is a way to hear and resolve applicant/beneficiary problems and dissatisfactions in a systematic, objective, and in an expedient manner.  This process does not change policy; it can only ensure that policy has been followed.

 

12.01.01B
Scope of Services and Payment Issues

CMS beneficiaries have the right to make a complaint or file an appeal with the ASO when they do not agree with the County’s actions concerning access to medical services, quality of care, scope of services, or payment of claims. Information on how to file a complaint or appeal with the ASO is available in the CMS Patient Handbook.

 

CMSPG LTR 29 (11/13)

 

12.01.01C
Eligibility Determination

1.    Individuals, who disagree with the eligibility determination of CMS, have the right to appeal the decision by filing a County Administrative Hearing.

2.    If the individual is dissatisfied with the County Hearing Officer’s decision, the individual may file an appeal with the San Diego County Superior Court.

 

CMSPG LTR 14 (07/13)

 

12.01.01D
Hearing Officer

The CMS Hearing Officer is a Program Specialist in the Appeals Section.  The Hearing Officer is responsible for conducting the hearing and ensuring that an applicant/beneficiary who has filed an appeal receives an impartial hearing decision.

 

CMSPG LTR 10 (03/12)