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Home  •  Waiver & Medicaid Services  •  CAP/C  •  What if I’m Denied?

Cap/C Waiver

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What if I’m Denied?

  1. Submit your appeal form to the Office of Administrative Hearings (OAH) within 30 days of the date of your denial letter to:

    Office of Administrative Hearings
    Attention: Clerk of Court

    1711 New Hope Church Road
    Raleigh, NC 27609

    Telephone: 984-236-1850    Fax: 984-236-1871
    Consider sending via Fax and keep receipt confirmation and/or sending via mail with delivery confirmation.

    ***If you are being denied services you are currently receiving, you must appeal within 10 days to continue receiving services during the appeal process time.

  2. Gather documentation (past or new) to counter the denial reason and submit to OAH within 3 business days prior to your mediation (not required, just best practice). Documentation might include things such as letters from physicians, therapists, & other service providers.
  1. The mediator will call you to schedule mediation. This will be a meeting between you and a Medicaid nurse consultant to discuss your case in the presence of a mediator. These are conducted by phone. HAVE SOMEONE ATTEND WITH YOU! Based on AFMFKNC experience, having a support person to act as a witness/scribe and/or a calming presence can significantly impact the outcome. 
  1. Attend mediation. Have your documentation in front of you and be familiar with it so you can reference it as needed. You may also want to share it with your support on the call. Remain calm and have a respectful conversation. 
  1. If you don’t come to an agreement at mediation, this is called an “impasse.” The next step is a preliminary hearing. You will be contacted at a later date to get this scheduled. This is also by phone. 
  1. For the preliminary hearing, an administrative court judge will initially be present, along with the Medicaid attorney. The judge will ask that everyone try to reach an agreement and then leave the call to allow the Medicaid attorney, the Medicaid nurse consultant, and you (and your support person/people) to try to reach an agreement. If still at an impasse, then scheduling a full hearing is next.
  1. A full hearing before the judge is also typically by phone. If you have any witnesses to testify, this is the time to coordinate with them to ensure they can participate in a conference call. 

Must meet one of the following nursing experience requirements:

  • A minimum of 1000 hours of experience in the previous two years in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
  • A minimum of 2000 hours of experience in the previous three years in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
  • A minimum of 2000 hours of experience in the previous five years, working for a licensed and certified home health agency caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
  • A minimum of 2000 hours of experience in the previous five years in an area not listed above that, in the opinion of DHHS, would demonstrate appropriate knowledge, skill, and ability in caring for individuals at one or more of the levels of care specified in this waiver.

Extraordinary Circumstances:

  1. There are not sufficient nurse aides in the waiver participant’s county or adjunct counties through a Home Health Agency/In-home aide agency due to a lack of qualified providers, and the waiver participant needs extensive to maximal assistance with bathing, dressing, toileting, and eating daily to avoid an out-of-home placement.

  2. The waiver participant requires short-term isolation, 90 days or less, due to experiencing an acute medical condition/healthcare issue requiring extensive to maximal assistance with bathing, dressing, toileting, and eating, and the waiver participant chooses to receive care in their home instead of an institution.

  3. The waiver participant requires physician-ordered 24-hour direct observation and/or supervision specifically related to the primary medical condition(s) to assure the health and welfare of the participant and avoid institutionalization, and the legal guardian is not able to maintain full or part-time employment due to multiple absences from work to monitor and/or supervise the waiver participant; regular interruption at work to assist with the management of the waiver participant’s monitoring/supervision needs; or employment termination.

  4. The waiver participant has specialized health care needs that can be only provided by the legal guardian, as indicated by medical documentation, and these health care needs require extensive to maximal assistance with bathing, dressing, toileting, and eating to assure the health and welfare of the participant and avoid institutionalization.

  5. Other documented extraordinary circumstances not previously mentioned places the waiver participant’s health, safety, and well-being in jeopardy resulting in an institutional placement.