Title 42, Part 431 — State Organization and General Administration

Purpose.

Single State agency.

Organization for administration.

Medicaid Advisory Committee and Beneficiary Advisory Council.

Methods of administration.

Reports.

Maintenance of records.

Availability of agency program manuals.

Advance directives.

Basis and scope.

Statewide operation.

Free choice of providers.

Payments for services furnished out of State.

Assurance of transportation.

Exceptions to certain State plan requirements.

Waiver of other Medicaid requirements.

Special waiver provisions applicable to American Samoa and the Northern Mariana Islands.

Beneficiary access to and exchange of data.

Access to and exchange of health data for providers and payers.

Access to published provider directory information.

Prior authorization requirements.

Consultation to medical facilities.

Required provider agreement.

Effective date of provider agreements.

Participation by Indian Health Service facilities.

Disclosure of survey information and provider or contractor evaluation.

State requirements with respect to nursing facilities.

Scope and applicability.

State plan requirements.

Evidentiary hearing.

Informal reconsideration for ICFs/IID.

Basis and scope.

Definitions.

State plan requirements.

Provision of hearing system.

Informing applicants and beneficiaries.

Content of notice.

Advance notice.

Exceptions from advance notice.

Notice in cases of probable fraud.

When a hearing is required.

Request for hearing.

Group hearings.

Denial or dismissal of request for a hearing.

Expedited appeals.

Maintaining services.

Reinstating services.

Adverse decision of local evidentiary hearing.

State agency hearing after adverse decision of local evidentiary hearing.

Conducting the hearing.

Matters to be considered at the hearing.

Procedural rights of the applicant or beneficiary.

Parties in cases involving an eligibility determination.

Hearing decisions.

Notifying the applicant or beneficiary of a State agency decision.

Corrective action.

Federal financial participation.

Basis and purpose.

State plan requirements.

Purposes directly related to State plan administration.

State authority for safeguarding information.

Publicizing safeguarding requirements.

Types of information to be safeguarded.

Release of information.

Distribution of information materials.

Basis and purpose.

Definitions.

State public notice process.

Application procedures.

Federal public notice and approval process.

Monitoring and compliance.

Evaluation requirements.

Reporting requirements.

Relations with standard-setting and survey agencies.

Relations with State health and vocational rehabilitation agencies and title V grantees.

Agreement with State mental health authority or mental institutions.

State requirements with respect to nursing facilities.

Coordination of Medicaid with Medicare part B.

Coordination of Medicaid with QIOs.

Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC).

Basis and purpose.

Definitions.

State plan requirement.

Licensing requirement.

Nursing homes designated by other terms.

Licensing authority.

Composition of licensing board.

Standards.

Procedures for applying standards.

Issuance and revocation of license.

Provisional licenses.

Compliance with standards.

Failure to comply with standards.

Continuing study and investigation.

Waivers.

Federal financial participation.

Basis and scope.

Definitions.

State requirements.

Protection of beneficiary rights.

Basic elements of the Medicaid Eligibility Quality Control (MEQC) Program.

Review procedures.

Pilot planning document.

Case review completion deadlines and submittal of reports.

Access to records.

Corrective action under the MEQC program.

Basic elements of the Medicaid quality control (MQC) claims processing assessment system.

Reporting requirements for claims processing assessment systems.

Access to records: Claims processing assessment systems.

Corrective action under the MQC claims processing assessment system.

Purpose.

Basis and scope.

Definitions and use of terms.

Types of payment errors.

Information submission and systems access requirements.

Claims sampling procedures.

Corrective action plan.

Difference resolution and appeal process.

Recoveries.

Disallowance of Federal financial participation for erroneous State payments (for PERM review years ending after July 1, 2020).