Medicaid Appeals to the Agency

After entry of an initial decision, the Clerk must certify the record, including the Initial Decision and any tapes or other recordings of the hearing, to the the parties upon request. Ga. R. & Regs. § 616-1-2-.33.

The Applicant or the Department may appeal. In Georgia, the OSAH decision is an initial decision. O.C.G.A. § 50-13-41(d)(2). The Department makes the final decision. “If a reviewing agency fails to reject or modify the decision of the administrative law judge within such 30 day period, then the decision of the administrative law judge shall stand affirmed by the reviewing agency by operation of law.” O.C.G.A. § 50-13-41(d)(3).

In making a final decision, the Department may extend the period for final review in any case wherein unusual and compelling circumstances render it impracticable for the reviewing agency to complete its review within the 30 day period, but must recite with particularity the circumstances which render it impracticable to do so. O.C.G.A. § 50-13-41(d)(4). The extended review period cannot exceed 30 days. If a reviewing agency fails to reject or modify the decision of the administrative law judge within the extended review period, then the decision of the administrative law judge shall stand affirmed by the reviewing agency by operation of law. O.C.G.A. § 50-13-41(d)(4). Through this process, the Department makes the ultimate decision regarding how to resolve an Applicant’s claim. O.C.G.A. § 50-13-17(a) would give the Department authority to take additional testimony or remand the case to the hearing representative for that purpose. It is unclear whether O.C.G.A. § 49-4-153(c) limits the Department’s ability to rely on the APA or whether it simply limits a reviewing Court’s ability to hold the Department to standards in the APA. See O.C.G.A. § 49-4-153(c) (“provided, however, that no other provision of Chapter 13 of Title 50 shall be applicable to the department with the exception of Code Sections 50-13-13 and 50-13-15“).

A review to the Department, which is an internal agency review, is not necessarily subject to the same limitations as subsequent appeals. In making its final decision, the Department is constrained only by the governing statute and by principles of due process. See Greene v. Department of Community Health, 293 Ga. App. 201, at 204 (2008), citing Bd. of Regents of State Colleges v. Roth, 408 U.S. 564 (1972) and Goldberg v. Kelly, 397 U.S. 254 (1970). The Court, in Greene, stated “While the Department is free to rule for a claimant because it is statutorily authorized to do so, it is not free to rule against a claimant as a result of misapplying a judicial standard of review that does not apply to an internal agency review.”

A final decision or order adverse to a party, other than the agency, in a contested case shall be in writing or stated in the record. A final decision shall include findings of fact and conclusions of law, separately stated, and the effective date of the decision or order. Findings of fact shall be accompanied by a concise and explicit statement of the underlying facts supporting the findings. O.C.G.A. § 49-4-153(b)(1).

Upon receipt of a copy of a petition for judicial review, pursuant to Rule 39, the Clerk shall compile and certify the record of the hearing and transmit it to the reviewing court. The Clerk also shall provide an electronic copy of this certified record to all parties of record in the case. Ga. R. & Regs. § 616-1-2-.33.