(A)The JFS 04022 "Notice of Medical Determination and a Right to a State Hearing" (rev. 3/2002)," or its computer-generated equivalent shall be mailed or personally delivered to the individual and authorized representative in the following situations:

(1)When, as the result of a preadmission review for long-term care, the local agency receives an authorization of a level of care that assigns a noninstitutional level of care, or a level of care that is different from the specific level of care certified by the individual's physician, the local agency shall send notice to the individual and authorized representative, with a copy of the notice filed in the individual's case record.

Notice is not required when the assigned level of care is different from the level of care certified by the individual's physician, but the individual is or will be placed in a facility with dual certification to provide the assigned level of care.

(2)When a request for prior authorization for additional hospital stays, visits, or therapeutic leave days beyond thirty days for a medicaid individual with a developmental disability level of care is denied, the local agency shall send the notice to the individual and authorized representative, with a copy of the notice filed in the individual's case record.

(3)When a review agency denies or modifies a request for precertification of a hospital admission or medical procedure, the review agency shall send the notice to the individual and authorized representative, with a copy of the notice sent to the local agency.

(B)The notice shall contain: a clear and understandable statement of the decision and the reasons for it, cite the applicable regulations, explain the individual's right to and the method of obtaining a state hearing, and contain a telephone number to call about free legal services.

(1)A clear and understandable statement of the decision and the reasons for it.

(2)Citations of the applicable regulations.

(3)An explanation of the individual's right to and the method of obtaining a state hearing.

(4)A telephone number to call about free legal services.

Effective: 3/1/2019

Five Year Review (FYR) Dates: 11/29/2018 and 03/01/2024

Certification: CERTIFIED ELECTRONICALLY

Date: 02/05/2019

Promulgated Under: 119.03

Statutory Authority: 5101.35

Rule Amplifies: 5101.35, 5160.011

Prior Effective Dates: 09/01/1976, 04/01/1980, 10/01/1981, 05/01/1982, 07/01/1982, 04/01/1983, 09/24/1983, 11/01/1983 (Temp.), 12/01/1983, 01/01/1984, 03/01/1984 (Temp.), 06/01/1984, 10/03/1984 (Emer.), 12/22/1984, 04/01/1986, 04/01/1987, 09/01/1987, 07/01/1988 (Emer.), 09/25/1988, 10/01/1989, 02/01/1990, 04/01/1991, 06/01/1993, 11/01/1994, 06/01/2003, 09/01/2008, 02/28/2014