Appeals Process
Appeals Process

As a provision of the law, States are required to establish a provider appeals process for eligibility, payments, and determinations of meaningful use for their Medicaid EHR Incentive Programs. An appellant may appeal any Program action or decision related to the Medicaid EHR Incentive Program, except those actions or decisions defined in federal or state law that are otherwise excluded from appeal. For example, rules and criteria for program eligibility, continued participation in the Program, and incentive payment calculations that are established by federal or state law are excluded from appeal.

New Jersey Medicaid will leverage its current provider appeals and fair hearing process for any provider complaints related to any facet of the EHR Incentive Program, including eligibility determinations, denials based on provider failure to demonstrate efforts to adopt, implement, or upgrade and meaningfully use certified EHR technology, and issues in processing the actual incentive payments. 

New Jersey Medicaid will clearly communicate the basis for denying an incentive payment request and will make every effort to review the provider's entire payment request to determine if there the incentive payment denial was due to an oversight in entering data into the incentive payment administrative solution or was due to a legitimate failure to meet the Incentive Program's eligibility criteria.

The appeals process will allow providers 20 days from a formal notice of agency action to request a hearing on their complaint.  The hearings will be conducted by an Administrative Law Judge from the New Jersey Office of Administrative Law and conducted pursuant to this Office's regulatory procedures with prompt, definitive, and final administrative action to be taken within 90 days from the hearing date. Providers will receive a written final decision from the Department and will have the right to pursue additional judicial review of this decision.