{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-325.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-325.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-325.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-325.1.html"}],"law_id":75066,"edition_id":1,"section_id":75066,"structure_id":13276,"section_number":"32.1-325.1","catch_line":"Appeals of agency determinations","history":"1986, c. 441; 2000, c. 967; 2025, cc. 621, 651.","full_text":"A\n\nAll providers enrolled with the Department may appeal any action by the Department or its contractor that is subject to appeal under the Administrative Process Act (§ 2.2-4000 et seq.). For provider appeals stemming from an action taken by a Department contractor, including managed care organizations, the provider shall exhaust the contractor’s internal reconsideration and internal appeal processes, if any, before appealing to the Department.B\n\nThe Department shall make an initial appeal determination in accordance with the state plan for medical assistance, the provisions of § 2.2-4019, and applicable federal law. The initial determination shall be issued within 180 days of the receipt of the appeal request. If the agency does not render a decision within 180 days, or, in the case of a joint agreement to stay the appeal decision pursuant to subsection D, within the time after the stay expires and before the appeal timeframe resumes, the decision is deemed to be in favor of the provider.C\n\nAn appeal of the Department’s initial determination concerning provider reimbursement shall be heard in accordance with § 2.2-4020 of the Administrative Process Act (§ 2.2-4020 et seq.) and the state plan for medical assistance provided for in § 32.1-325. The hearing officer appointed pursuant to § 2.2-4024 shall conduct the appeal and submit a recommended decision to the Director within 120 days of the agency’s receipt of the appeal request, unless the settlement provisions of this section apply. The Director shall consider the parties’ exceptions and issue the final agency case decision within 60 days of receipt of the hearing officer’s recommended decision. If the Director does not render a final agency case decision within 60 days of the receipt of the hearing officer’s recommended decision, the decision is deemed to be in favor of the provider. The Director shall adopt the hearing officer’s recommended decision unless to do so would be an error of law or Department policy. Any final agency case decision in which the Director rejects a hearing officer’s recommended decision shall state with particularity the basis for rejection. Prior to a final agency case decision issued in accordance with § 2.2-4023, the Director may not undertake recovery of any overpayment amount paid to the provider through offset or other means. Once a final determination of overpayment has been made, the Director shall undertake full recovery of such overpayment whether or not the provider disputes, in whole or in part, the initial or the final determination of overpayment. Interest charges on the unpaid balance of any overpayment shall accrue pursuant to § 32.1-313 from the date the Department’s determination becomes final. Nothing in § 32.1-313 shall be construed to require interest payments on any portion of overpayment other than the unpaid balance referenced herein.D\n\nThe Department and the provider may jointly agree to stay the deadline for the informal appeal decision or for the formal appeal recommended decision of the hearing officer for a period of up to 60 days to facilitate settlement discussions. If the parties reach a resolution as reflected by a written settlement agreement within the 60-day period, then the stay shall be extended for such additional time as may be necessary for review and approval of the settlement agreement in accordance with § 2.2-514.E\n\nThe burden of proof in informal and formal administrative appeals is on the provider. If an action stems from a Department contractor, then such contractor shall represent itself during the informal and formal appeal proceedings. No such contractor, including managed care organizations, shall have the right to file a petition for reconsideration or an appeal for court review of the Department’s final agency decision.F\n\nThe agency shall reimburse a provider for reasonable and necessary attorney fees and costs associated with an informal or formal administrative appeal if the provider substantially prevails on the merits of the appeal and the agency’s position is not substantially justified, unless special circumstances would make an award unjust. In any case in which a provider has recovered attorney fees and costs associated with an informal or formal administrative appeal, the provider shall not be entitled to recover those same attorney fees and costs in a subsequent judicial proceeding.G\n\nCourt review of final agency determinations concerning provider reimbursement shall be made in accordance with the Administrative Process Act (§ 2.2-4000 et seq.). In any case in which a final determination of overpayment has been reversed in a subsequent judicial proceeding, the provider shall be reimbursed that portion of the payment to which he is entitled plus any applicable interest, within 30 days of the subsequent judicial order.","order_by":null,"text":{"0":{"id":269618,"text":"All providers enrolled with the Department may appeal any action by the Department or its contractor that is subject to appeal under the Administrative Process Act (§ 2.2-4000 et seq.). For provider appeals stemming from an action taken by a Department contractor, including managed care organizations, the provider shall exhaust the contractor’s internal reconsideration and internal appeal processes, if any, before appealing to the Department.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":269619,"text":"The Department shall make an initial appeal determination in accordance with the state plan for medical assistance, the provisions of § 2.2-4019, and applicable federal law. The initial determination shall be issued within 180 days of the receipt of the appeal request. If the agency does not render a decision within 180 days, or, in the case of a joint agreement to stay the appeal decision pursuant to subsection D, within the time after the stay expires and before the appeal timeframe resumes, the decision is deemed to be in favor of the provider.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":269620,"text":"An appeal of the Department’s initial determination concerning provider reimbursement shall be heard in accordance with § 2.2-4020 of the Administrative Process Act (§ 2.2-4020 et seq.) and the state plan for medical assistance provided for in § 32.1-325. The hearing officer appointed pursuant to § 2.2-4024 shall conduct the appeal and submit a recommended decision to the Director within 120 days of the agency’s receipt of the appeal request, unless the settlement provisions of this section apply. The Director shall consider the parties’ exceptions and issue the final agency case decision within 60 days of receipt of the hearing officer’s recommended decision. If the Director does not render a final agency case decision within 60 days of the receipt of the hearing officer’s recommended decision, the decision is deemed to be in favor of the provider. The Director shall adopt the hearing officer’s recommended decision unless to do so would be an error of law or Department policy. Any final agency case decision in which the Director rejects a hearing officer’s recommended decision shall state with particularity the basis for rejection. Prior to a final agency case decision issued in accordance with § 2.2-4023, the Director may not undertake recovery of any overpayment amount paid to the provider through offset or other means. Once a final determination of overpayment has been made, the Director shall undertake full recovery of such overpayment whether or not the provider disputes, in whole or in part, the initial or the final determination of overpayment. Interest charges on the unpaid balance of any overpayment shall accrue pursuant to § 32.1-313 from the date the Department’s determination becomes final. Nothing in § 32.1-313 shall be construed to require interest payments on any portion of overpayment other than the unpaid balance referenced herein.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":269621,"text":"The Department and the provider may jointly agree to stay the deadline for the informal appeal decision or for the formal appeal recommended decision of the hearing officer for a period of up to 60 days to facilitate settlement discussions. If the parties reach a resolution as reflected by a written settlement agreement within the 60-day period, then the stay shall be extended for such additional time as may be necessary for review and approval of the settlement agreement in accordance with § 2.2-514.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":269622,"text":"The burden of proof in informal and formal administrative appeals is on the provider. If an action stems from a Department contractor, then such contractor shall represent itself during the informal and formal appeal proceedings. No such contractor, including managed care organizations, shall have the right to file a petition for reconsideration or an appeal for court review of the Department’s final agency decision.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":269623,"text":"The agency shall reimburse a provider for reasonable and necessary attorney fees and costs associated with an informal or formal administrative appeal if the provider substantially prevails on the merits of the appeal and the agency’s position is not substantially justified, unless special circumstances would make an award unjust. In any case in which a provider has recovered attorney fees and costs associated with an informal or formal administrative appeal, the provider shall not be entitled to recover those same attorney fees and costs in a subsequent judicial proceeding.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":269624,"text":"Court review of final agency determinations concerning provider reimbursement shall be made in accordance with the Administrative Process Act (§ 2.2-4000 et seq.). In any case in which a final determination of overpayment has been reversed in a subsequent judicial proceeding, the provider shall be reimbursed that portion of the payment to which he is entitled plus any applicable interest, within 30 days of the subsequent judicial order.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F"}},"ancestry":[{"id":13276,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":13275,"metadata":{},"date_created":"2026-06-26 03:44:33","date_modified":"2026-06-26 03:44:33","permalink":{"id":201355,"object_type":"structure","relational_id":13276,"identifier":"1","token":"32.1\/10\/1","url":"\/32.1\/10\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13275,"edition_id":1,"name":"Department of Medical Assistance Services","identifier":"10","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:44:33","date_modified":"2026-06-26 03:44:33","permalink":{"id":201353,"object_type":"structure","relational_id":13275,"identifier":"10","token":"32.1\/10","url":"\/32.1\/10\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":75748,"structure_id":13276,"section_number":"32.1-323","catch_line":"Department of Medical Assistance Services","url":"\/32.1-323\/","token":"32.1\/10\/1\/32.1-323","metadata":false},{"id":73079,"structure_id":13276,"section_number":"32.1-323.1","catch_line":"Department to submit forecast of expenditures","url":"\/32.1-323.1\/","token":"32.1\/10\/1\/32.1-323.1","metadata":false},{"id":78209,"structure_id":13276,"section_number":"32.1-323.2","catch_line":"Elimination of waiting lists for certain waivers","url":"\/32.1-323.2\/","token":"32.1\/10\/1\/32.1-323.2","metadata":false},{"id":65434,"structure_id":13276,"section_number":"32.1-323.3","catch_line":"Dependents of foreign service members; waiting lists for certain waivers","url":"\/32.1-323.3\/","token":"32.1\/10\/1\/32.1-323.3","metadata":false},{"id":74370,"structure_id":13276,"section_number":"32.1-323.4","catch_line":"Department to facilitate transition of persons between certain waiver programs","url":"\/32.1-323.4\/","token":"32.1\/10\/1\/32.1-323.4","metadata":false},{"id":56444,"structure_id":13276,"section_number":"32.1-324","catch_line":"Board of Medical Assistance Services","url":"\/32.1-324\/","token":"32.1\/10\/1\/32.1-324","metadata":false},{"id":82951,"structure_id":13276,"section_number":"32.1-324.1","catch_line":"Authority to administer oaths, conduct hearings; obtaining relevant documents and other information","url":"\/32.1-324.1\/","token":"32.1\/10\/1\/32.1-324.1","metadata":false},{"id":68172,"structure_id":13276,"section_number":"32.1-324.2","catch_line":"Director to facilitate communication","url":"\/32.1-324.2\/","token":"32.1\/10\/1\/32.1-324.2","metadata":false},{"id":75151,"structure_id":13276,"section_number":"32.1-324.3","catch_line":"Uninsured Medical Catastrophe Fund established","url":"\/32.1-324.3\/","token":"32.1\/10\/1\/32.1-324.3","metadata":false},{"id":77747,"structure_id":13276,"section_number":"32.1-325","catch_line":"Board to submit plan for medical assistance services to U.S. Secretary of Health and Human Services pursuant to federal law; administration of plan; contracts with health care providers","url":"\/32.1-325\/","token":"32.1\/10\/1\/32.1-325","metadata":false},{"id":76231,"structure_id":13276,"section_number":"32.1-325.001","catch_line":"Repealed","url":"\/32.1-325.001\/","token":"32.1\/10\/1\/32.1-325.001","metadata":false},{"id":83706,"structure_id":13276,"section_number":"32.1-325.01","catch_line":"Certain term life insurance considered resources","url":"\/32.1-325.01\/","token":"32.1\/10\/1\/32.1-325.01","metadata":false},{"id":54270,"structure_id":13276,"section_number":"32.1-325.02","catch_line":"Determinations of assets; disclaimers of interests to be considered uncompensated transfers of assets for Medicaid eligibility purposes under certain circumstances","url":"\/32.1-325.02\/","token":"32.1\/10\/1\/32.1-325.02","metadata":false},{"id":73332,"structure_id":13276,"section_number":"32.1-325.03","catch_line":"Legal presence required for certain state and local public benefits; exceptions; definitions; proof of legal presence","url":"\/32.1-325.03\/","token":"32.1\/10\/1\/32.1-325.03","metadata":false},{"id":83713,"structure_id":13276,"section_number":"32.1-325.04","catch_line":"Eligibility for medical assistance; individuals confined in state correctional facilities","url":"\/32.1-325.04\/","token":"32.1\/10\/1\/32.1-325.04","metadata":false},{"id":75066,"structure_id":13276,"section_number":"32.1-325.1","catch_line":"Appeals of agency determinations","url":"\/32.1-325.1\/","token":"32.1\/10\/1\/32.1-325.1","metadata":false},{"id":87103,"structure_id":13276,"section_number":"32.1-325.1:1","catch_line":"Definitions; recovery of overpayment for medical assistance services","url":"\/32.1-325.1_1\/","token":"32.1\/10\/1\/32.1-325.1_1","metadata":false},{"id":56047,"structure_id":13276,"section_number":"32.1-325.2","catch_line":"Department is payor of last resort","url":"\/32.1-325.2\/","token":"32.1\/10\/1\/32.1-325.2","metadata":false},{"id":60758,"structure_id":13276,"section_number":"32.1-325.3","catch_line":"Disclosure or use of information for purpose not connected with medical assistance program; Department not subject to certain disclosure","url":"\/32.1-325.3\/","token":"32.1\/10\/1\/32.1-325.3","metadata":false},{"id":55595,"structure_id":13276,"section_number":"32.1-325.4","catch_line":"Penalty for violation","url":"\/32.1-325.4\/","token":"32.1\/10\/1\/32.1-325.4","metadata":false},{"id":60835,"structure_id":13276,"section_number":"32.1-325.5","catch_line":"State pharmacy benefits manager","url":"\/32.1-325.5\/","token":"32.1\/10\/1\/32.1-325.5","metadata":false},{"id":62094,"structure_id":13276,"section_number":"32.1-326","catch_line":"Director may make payments to or for eligible persons in state-owned medical facilities","url":"\/32.1-326\/","token":"32.1\/10\/1\/32.1-326","metadata":false},{"id":75399,"structure_id":13276,"section_number":"32.1-326.1","catch_line":"Department to operate program of estate recovery","url":"\/32.1-326.1\/","token":"32.1\/10\/1\/32.1-326.1","metadata":false},{"id":86309,"structure_id":13276,"section_number":"32.1-326.2","catch_line":"Pilot school\/community health centers","url":"\/32.1-326.2\/","token":"32.1\/10\/1\/32.1-326.2","metadata":false},{"id":69227,"structure_id":13276,"section_number":"32.1-326.3","catch_line":"Special education health services; memorandum of agreement between the Department of Education and the Department of Medical Assistance Services","url":"\/32.1-326.3\/","token":"32.1\/10\/1\/32.1-326.3","metadata":false},{"id":81598,"structure_id":13276,"section_number":"32.1-327","catch_line":"Claim against indigent's estate for payments made","url":"\/32.1-327\/","token":"32.1\/10\/1\/32.1-327","metadata":false},{"id":59946,"structure_id":13276,"section_number":"32.1-328","catch_line":"Repealed","url":"\/32.1-328\/","token":"32.1\/10\/1\/32.1-328","metadata":false},{"id":74371,"structure_id":13276,"section_number":"32.1-329","catch_line":"Repealed","url":"\/32.1-329\/","token":"32.1\/10\/1\/32.1-329","metadata":false},{"id":85726,"structure_id":13276,"section_number":"32.1-330","catch_line":"Long-term services and supports screening required","url":"\/32.1-330\/","token":"32.1\/10\/1\/32.1-330","metadata":false},{"id":80319,"structure_id":13276,"section_number":"32.1-330.01","catch_line":"Reports related to long-term services and supports","url":"\/32.1-330.01\/","token":"32.1\/10\/1\/32.1-330.01","metadata":false},{"id":56351,"structure_id":13276,"section_number":"32.1-330.02","catch_line":"Average hourly payment rates; publication","url":"\/32.1-330.02\/","token":"32.1\/10\/1\/32.1-330.02","metadata":false},{"id":75895,"structure_id":13276,"section_number":"32.1-330.1","catch_line":"Department to implement premium assistance program for HIV-positive individuals","url":"\/32.1-330.1\/","token":"32.1\/10\/1\/32.1-330.1","metadata":false},{"id":67982,"structure_id":13276,"section_number":"32.1-330.2","catch_line":"Medicaid managed care programs; program information documents; plain language required","url":"\/32.1-330.2\/","token":"32.1\/10\/1\/32.1-330.2","metadata":false},{"id":67859,"structure_id":13276,"section_number":"32.1-330.3","catch_line":"Operation of a PACE plan; oversight by Department of Medical Assistance Services","url":"\/32.1-330.3\/","token":"32.1\/10\/1\/32.1-330.3","metadata":false},{"id":85218,"structure_id":13276,"section_number":"32.1-330.4","catch_line":"Uniform assessment instrument for PACE plans","url":"\/32.1-330.4\/","token":"32.1\/10\/1\/32.1-330.4","metadata":false},{"id":56407,"structure_id":13276,"section_number":"32.1-330.5","catch_line":"Reports related to eligibility renewal","url":"\/32.1-330.5\/","token":"32.1\/10\/1\/32.1-330.5","metadata":false},{"id":59199,"structure_id":13276,"section_number":"32.1-331","catch_line":"Repealed","url":"\/32.1-331\/","token":"32.1\/10\/1\/32.1-331","metadata":false},{"id":60720,"structure_id":13276,"section_number":"32.1-331.01","catch_line":"Health Care Coverage Assessment Fund","url":"\/32.1-331.01\/","token":"32.1\/10\/1\/32.1-331.01","metadata":false},{"id":76953,"structure_id":13276,"section_number":"32.1-331.02","catch_line":"Health Care Provider Payment Rate Assessment Fund","url":"\/32.1-331.02\/","token":"32.1\/10\/1\/32.1-331.02","metadata":false},{"id":79240,"structure_id":13276,"section_number":"32.1-331.03","catch_line":"Process for payment directly to nursing facility or ICF\/MR","url":"\/32.1-331.03\/","token":"32.1\/10\/1\/32.1-331.03","metadata":false},{"id":80605,"structure_id":13276,"section_number":"32.1-331.04","catch_line":"Personal care aides; orientation program","url":"\/32.1-331.04\/","token":"32.1\/10\/1\/32.1-331.04","metadata":false},{"id":84036,"structure_id":13276,"section_number":"32.1-331.05","catch_line":"Coordinated specialty care; work group","url":"\/32.1-331.05\/","token":"32.1\/10\/1\/32.1-331.05","metadata":false},{"id":77511,"structure_id":13276,"section_number":"32.1-331.06","catch_line":"Annual review of medications and treatment for sickle cell disease; report","url":"\/32.1-331.06\/","token":"32.1\/10\/1\/32.1-331.06","metadata":false}],"previous_section":{"id":83713,"structure_id":13276,"section_number":"32.1-325.04","catch_line":"Eligibility for medical assistance; individuals confined in state correctional facilities","url":"\/32.1-325.04\/","token":"32.1\/10\/1\/32.1-325.04","metadata":false},"next_section":{"id":87103,"structure_id":13276,"section_number":"32.1-325.1:1","catch_line":"Definitions; recovery of overpayment for medical assistance services","url":"\/32.1-325.1_1\/","token":"32.1\/10\/1\/32.1-325.1_1","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-325.1\/","history_text":"

This law was first created in 1986. The record of its establishment is cataloged in chapter 441 of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. Unfortunately, the 1986 \u201cActs\u201d aren\u2019t available online. It has been modified 2 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 2000, chapter 967<\/a>; in 2025, chapters 621<\/a> and 651<\/a>.<\/p>","references":[{"id":64118,"section_number":"2.2-4020.2","catch_line":"Default","order_by":null,"url":"\/2.2-4020.2\/"},{"id":87103,"section_number":"32.1-325.1:1","catch_line":"Definitions; recovery of overpayment for medical assistance services","order_by":null,"url":"\/32.1-325.1_1\/"}],"refers_to":[{"id":86911,"section_number":"2.2-4000","catch_line":"Short title; purpose","order_by":null,"url":"\/2.2-4000\/"},{"id":85983,"section_number":"2.2-4019","catch_line":"Informal fact finding proceedings","order_by":null,"url":"\/2.2-4019\/"},{"id":71957,"section_number":"2.2-4020","catch_line":"Formal hearings; litigated issues","order_by":null,"url":"\/2.2-4020\/"},{"id":62092,"section_number":"2.2-4023","catch_line":"Final orders","order_by":null,"url":"\/2.2-4023\/"},{"id":57586,"section_number":"2.2-4024","catch_line":"Hearing officers","order_by":null,"url":"\/2.2-4024\/"},{"id":78625,"section_number":"32.1-313","catch_line":"Liability for excess benefits or payments obtained without intent to violate chapter","order_by":null,"url":"\/32.1-313\/"},{"id":77747,"section_number":"32.1-325","catch_line":"Board to submit plan for medical assistance services to U.S. Secretary of Health and Human Services pursuant to federal law; administration of plan; contracts with health care providers","order_by":null,"url":"\/32.1-325\/"}],"permalink":{"id":201417,"object_type":"law","relational_id":75066,"identifier":"32.1-325.1","token":"32.1\/10\/1\/32.1-325.1","url":"\/32.1-325.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-325.1\/","token":"32.1\/10\/1\/32.1-325.1","dublin_core":{"Title":"Appeals of agency determinations","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-325.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> All providers enrolled with the Department<\/span> may appeal<\/span> any action by the Department<\/span> or its contractor that is subject to appeal<\/span> under the Administrative Process Act (§ 2.2-4000<\/a> et seq.). For provider appeals<\/span> stemming from an action taken by a Department<\/span> contractor, including managed care organizations, the provider shall exhaust the contractor’s internal reconsideration and internal appeal<\/span> processes, if any, before appealing to the Department<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The Department<\/span> shall make an initial appeal<\/span> determination in accordance with the state plan for medical assistance, the provisions of § 2.2-4019<\/a>, and applicable federal law<\/span>. The initial determination shall be issued within 180 days of the receipt of the appeal<\/span> request. If the agency does not render a decision within 180 days, or, in the case of a joint agreement to stay<\/span> the appeal<\/span> decision pursuant to subsection D, within the time after the stay<\/span> expires and before the appeal<\/span> timeframe resumes, the decision is deemed to be in favor of the provider. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> An appeal<\/span> of the Department<\/span>’s initial determination concerning provider reimbursement shall be heard in accordance with § 2.2-4020<\/a> of the Administrative Process Act (§ 2.2-4020<\/a> et seq.) and the state plan for medical assistance provided for in § 32.1-325<\/a>. The hearing<\/span> officer appointed pursuant to § 2.2-4024<\/a> shall conduct the appeal<\/span> and submit a recommended decision to the Director within 120 days of the agency’s receipt of the appeal<\/span> request, unless the settlement<\/span> provisions of this section apply. The Director shall consider the parties’ exceptions and issue<\/span> the final agency case decision within 60 days of receipt of the hearing<\/span> officer’s recommended decision. If the Director does not render a final agency case decision within 60 days of the receipt of the hearing<\/span> officer’s recommended decision, the decision is deemed to be in favor of the provider. The Director shall adopt the hearing<\/span> officer’s recommended decision unless to do so would be an error of law<\/span> or Department<\/span> policy. Any final agency case decision in which the Director rejects a hearing<\/span> officer’s recommended decision shall state with particularity the basis for rejection. Prior to a final agency case decision issued in accordance with § 2.2-4023<\/a>, the Director may not undertake recovery of any overpayment amount paid to the provider through offset or other means. Once a final determination of overpayment has been made, the Director shall undertake full recovery of such overpayment whether or not the provider disputes, in whole or in part, the initial or the final determination of overpayment. Interest charges on the unpaid balance of any overpayment shall accrue pursuant to § 32.1-313<\/a> from the date the Department<\/span>’s determination becomes final. Nothing in § 32.1-313<\/a> shall be construed to require interest payments on any portion of overpayment other than the unpaid balance referenced herein. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The Department<\/span> and the provider may jointly agree to stay<\/span> the deadline for the informal appeal<\/span> decision or for the formal appeal<\/span> recommended decision of the hearing<\/span> officer for a period of up to 60 days to facilitate settlement<\/span> discussions. If the parties reach a resolution as reflected by a written settlement<\/span> agreement within the 60-day period, then the stay<\/span> shall be extended for such additional time as may be necessary for review and approval of the settlement<\/span> agreement in accordance with § 2.2-514<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The burden of proof<\/span> in informal and formal administrative appeals<\/span> is on the provider. If an action stems from a Department<\/span> contractor, then such contractor shall represent itself during the informal and formal appeal<\/span> proceedings. No such contractor, including managed care organizations, shall have the right to file a petition<\/span> for reconsideration or an appeal<\/span> for court<\/span> review of the Department<\/span>’s final agency decision. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The agency shall reimburse a provider for reasonable and necessary attorney fees and costs associated with an informal or formal administrative appeal<\/span> if the provider substantially prevails on the merits of the appeal<\/span> and the agency’s position is not substantially justified, unless special circumstances would make an award unjust. In any case in which a provider has recovered attorney fees and costs associated with an informal or formal administrative appeal<\/span>, the provider shall not be entitled to recover those same attorney fees and costs in a subsequent judicial proceeding. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> Court<\/span> review of final agency determinations concerning provider reimbursement shall be made in accordance with the Administrative Process Act (§ 2.2-4000<\/a> et seq.). In any case in which a final determination of overpayment has been reversed in a subsequent judicial proceeding, the provider shall be reimbursed that portion of the payment to which he is entitled plus any applicable interest, within 30 days of the subsequent judicial order<\/span>. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nAPPEALS OF AGENCY DETERMINATIONS (\u00a7 32.1-325.1)\n\nA. All providers enrolled with the Department may appeal any action by the\nDepartment or its contractor that is subject to appeal under the Administrative\nProcess Act (§ 2.2-4000 et seq.). For provider appeals stemming from an\naction taken by a Department contractor, including managed care organizations,\nthe provider shall exhaust the contractor’s internal reconsideration and\ninternal appeal processes, if any, before appealing to the Department.\n\nB. The Department shall make an initial appeal determination in accordance with\nthe state plan for medical assistance, the provisions of § 2.2-4019, and\napplicable federal law. The initial determination shall be issued within 180\ndays of the receipt of the appeal request. If the agency does not render a\ndecision within 180 days, or, in the case of a joint agreement to stay the\nappeal decision pursuant to subsection D, within the time after the stay expires\nand before the appeal timeframe resumes, the decision is deemed to be in favor\nof the provider.\n\nC. An appeal of the Department’s initial determination concerning provider\nreimbursement shall be heard in accordance with § 2.2-4020 of the\nAdministrative Process Act (§ 2.2-4020 et seq.) and the state plan for\nmedical assistance provided for in § 32.1-325. The hearing officer\nappointed pursuant to § 2.2-4024 shall conduct the appeal and submit a\nrecommended decision to the Director within 120 days of the agency’s\nreceipt of the appeal request, unless the settlement provisions of this section\napply. The Director shall consider the parties’ exceptions and issue the\nfinal agency case decision within 60 days of receipt of the hearing\nofficer’s recommended decision. If the Director does not render a final\nagency case decision within 60 days of the receipt of the hearing\nofficer’s recommended decision, the decision is deemed to be in favor of\nthe provider. The Director shall adopt the hearing officer’s recommended\ndecision unless to do so would be an error of law or Department policy. Any\nfinal agency case decision in which the Director rejects a hearing\nofficer’s recommended decision shall state with particularity the basis\nfor rejection. Prior to a final agency case decision issued in accordance with\n§ 2.2-4023, the Director may not undertake recovery of any overpayment\namount paid to the provider through offset or other means. Once a final\ndetermination of overpayment has been made, the Director shall undertake full\nrecovery of such overpayment whether or not the provider disputes, in whole or\nin part, the initial or the final determination of overpayment. Interest charges\non the unpaid balance of any overpayment shall accrue pursuant to §\n32.1-313 from the date the Department’s determination becomes final.\nNothing in § 32.1-313 shall be construed to require interest payments on\nany portion of overpayment other than the unpaid balance referenced herein.\n\nD. The Department and the provider may jointly agree to stay the deadline for\nthe informal appeal decision or for the formal appeal recommended decision of\nthe hearing officer for a period of up to 60 days to facilitate settlement\ndiscussions. If the parties reach a resolution as reflected by a written\nsettlement agreement within the 60-day period, then the stay shall be extended\nfor such additional time as may be necessary for review and approval of the\nsettlement agreement in accordance with § 2.2-514.\n\nE. The burden of proof in informal and formal administrative appeals is on the\nprovider. If an action stems from a Department contractor, then such contractor\nshall represent itself during the informal and formal appeal proceedings. No\nsuch contractor, including managed care organizations, shall have the right to\nfile a petition for reconsideration or an appeal for court review of the\nDepartment’s final agency decision.\n\nF. The agency shall reimburse a provider for reasonable and necessary attorney\nfees and costs associated with an informal or formal administrative appeal if\nthe provider substantially prevails on the merits of the appeal and the\nagency’s position is not substantially justified, unless special\ncircumstances would make an award unjust. In any case in which a provider has\nrecovered attorney fees and costs associated with an informal or formal\nadministrative appeal, the provider shall not be entitled to recover those same\nattorney fees and costs in a subsequent judicial proceeding.\n\nG. Court review of final agency determinations concerning provider reimbursement\nshall be made in accordance with the Administrative Process Act (§ 2.2-4000\net seq.). In any case in which a final determination of overpayment has been\nreversed in a subsequent judicial proceeding, the provider shall be reimbursed\nthat portion of the payment to which he is entitled plus any applicable\ninterest, within 30 days of the subsequent judicial order.\n\nHISTORY: 1986, c. 441; 2000, c. 967; 2025, cc. 621, 651.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}