Section 120.110 Appeals and fair hearings

Section 120

Section 120.110  Appeals and

fair hearings

a)         The Individual, parents, guardian, or the Individual's

representative may appeal the following actions:

1)         Refusal of the Division or ISC agency to accept a request for Waiver

program enrollment.

2)         Failure of the Division or ISC agency to act on a request for

services within the mandated time period.

3)         Denial of a requested Waiver service by the Division or ISC

agency (i.e., Individual in Home-Based Supports and is now requesting Assistive

Technology).

4)         Denial of clinical eligibility by the Division or an ISC

agency.

5)         Suspension, termination, or reduction of services by the

Division or a provider agency.

b)         The desire to appeal any action listed under subsection (a)

shall be communicated to the ISC within 10 working days after the date the

Individual or guardian receives the notice of action from the provider.  The

communication shall be followed by a written request to appeal signed by the

Individual, parent, guardian, or Individual's representative.

c)         Within 45 days after receiving notification to appeal, the ISC

must:

1)         Gather the following:

A)        The written request to appeal signed by the Individual, parent,

guardian, or Individual's representative.

B)        A complete appeal checklist.

C)        A complete Documentation for Medicaid Waiver Appeals form (IL444-0171)

and supporting documents as indicated in the form.

D)        Documents from the provider agency to support its decision to

suspend, terminate, or reduce services.

E)        Any additional documentation relevant to the appeal.

2)         Submit the documents pursuant to subsections (c)(1)(A) through

(E) to DDD's Appeals Unit by:

A)        Secure email

or Medicaid Waiver Appeals form (IL444-0171)

and supporting documents as indicated in the form.

D)        Documents from the provider agency to support its decision to

suspend, terminate, or reduce services.

E)        Any additional documentation relevant to the appeal.

2)         Submit the documents pursuant to subsections (c)(1)(A) through

(E) to DDD's Appeals Unit by:

A)        Secure email.  Emails should be directed to DHS.DDDAppeals@illinois.gov;

B)        Fax to 217-558-2799 Attn:  Appeals Unit supervisor; or

C)        Mail to:

DHS/DDD –

Program Development

Attn:  Appeals

Unit Supervisor

600 East Ash

Street Building 400, 3

rd

Floor South

Springfield,

IL  62703

d)         Within 30 working days after the appeal and supporting documents

indicated in subsection (c)(1) are received, DDD shall conduct an informal

review of the appealed action listed in subsection (a) and either uphold or not

uphold the appealed action.  The Individual, parent, guardian, or Individual's

representative (if any), and the service providers shall be notified in writing

of DDD's decision within 10 working days after the informal review is

complete.  The written notification shall include:

1)         A clear statement of the action to be taken;

2)         A clear statement of the reason for the action;

3)         A specific policy reference which supports such action; and

4)         A complete statement of the Individual's right to continue the

appeal and have an Administrative Hearing with HFS.  When DDD's Informal Review

decision does not support the Individual's appeal, the Individual, parent,

guardian, the Individual's representative, and provider, if applicable, will be

notified that the appeal will continue to HFS for an Administrative Hearing.

e)         When DDD's informal review decision does not support the

Individual's appeal, within 10 working days after the decision, DDD shall

forward the appeal and all documents reviewed to HFS for an administrative

hearing to be scheduled by HFS

, the Individual's representative, and provider, if applicable, will be

notified that the appeal will continue to HFS for an Administrative Hearing.

e)         When DDD's informal review decision does not support the

Individual's appeal, within 10 working days after the decision, DDD shall

forward the appeal and all documents reviewed to HFS for an administrative

hearing to be scheduled by HFS.

f)         The hearing shall be conducted by an impartial hearing officer

appointed by HFS.

g)         The hearing may be held by telephone.

h)         HFS' hearing rules for assistance appeals, as set forth at 89

Ill. Adm. Code 104, shall apply, except that subsection (d) shall apply rather

than any similar HFS rule.

i)          Following the hearing, the Director of HFS shall issue a

final administrative decision in accordance with 89 Ill. Adm. Code 104.70.

Copies of the decision shall be mailed to the Individual, guardian, parent, the

Individual’s representative (if any), the provider, and the Supervisor of DDD's

Appeals Unit.

j)          The receipt of the appeal shall stay the decision pending the

final administrative decision or the withdrawal of the appeal.  If the decision

being appealed is regarding suspension, termination, or reduction of services,

services shall not be suspended, terminated, or reduced until the appeal is

resolved, except as described below.

1)         Services may be suspended, terminated, or reduced before the

final administrative decision when:

A)        The physical safety or health of the Individual or others is in

extreme risk of harm; or

B)        Appropriate medical services are not available at the provider

agency thereby jeopardizing the health of the Individual; and

C)        The ISC agency has:

i)          Reviewed the Individual's record and clinical information;

ii)         Reviewed the actions, including the supports implemented, of

the provider;

iii)        Discussed the current situation and alternatives available

with the Individual and guardian;

iv)

e not available at the provider

agency thereby jeopardizing the health of the Individual; and

C)        The ISC agency has:

i)          Reviewed the Individual's record and clinical information;

ii)         Reviewed the actions, including the supports implemented, of

the provider;

iii)        Discussed the current situation and alternatives available

with the Individual and guardian;

iv)        Determined that a delay in termination, suspension, or

reduction in services would put the safety of the Individual or others in

extreme risk of harm and has documented that fact in the Individual's record;

and

v)         Consulted with the Division of Developmental Disabilities.

2)         If the conditions of subsection (j)(1) are met, services to

the Individual may be terminated, suspended, or reduced and the notice of

action shall be given in accordance with Section 120.70(h) as soon as possible,

but in no case later than 48 hours before the termination, suspension, or

reduction in services.

3)         The provider shall continue to provide services until the

appeal is resolved except as described in subsection (j)(l).

4)         If the conditions of subsections (j)(l)(A) or (B) exist, the Individual

(if possible), the guardian, the ISC agency, and a Department representative

will work together to secure alternative services.  The provider agency

(including the QIDP) shall work cooperatively with the Individual, the

guardian, the ISC agency and the Department in effort to secure and transition

Individuals to alternative services.  This includes, but is not limited to,

supplying records and other documents, supplying the Individual's personal

items, and conferencing with prospective agencies regarding the Individual's care.