SECTION 317:2-1-15. Supplemental Hospital Offset Payment Program (SHOPP) Appeals

(a)   In accordance with Title 63 of the Oklahoma Statutes Section 3241.4 OHCA is authorized to promulgate rules for appeals of annual assessments, fees and penalties to hospitals as defined by the statute. The rules in this Section describe those appeals rights.

(1)   OAC 317:30-5-58 subsections (a) through (e) describe the SHOPP Assessments, fees and the penalties for non-payment of the fee or failure to file a cost report, as set out in 63 Okla. Stat. §§ 3241.3 and 3241.4

(2)   Appeals filed under this Section are heard by an Administrative Law Judge (ALJ).

(3)   To file an appeal, the provider hospital must file an LD-2 form within thirty (30) days of receipt of the notification from OHCA assessing the annual SHOPP Assessment, a fee or penalty. The penalty, fee or assessment is deducted from the hospital's payment if the assessment is unpaid at the time the appeal is filed. If the hospital prevails in the appeal the amount assessed will be returned to the hospital with their payment.

(4)   The hearing will be conducted in accordance with OAC 317:2-1-5.

(b)   An individual hospital may appeal an individual assessment at the time of its annual assessment. As provided for above in subsection (3), the appeal must be filed within thirty (30) days of receipt of the notification of assessment by OHCA to the hospital. If the hospital challenges the computation of the hospital's net patient revenue, the assessment rate, or assessment amount then the appeal will proceed in accordance with subsection(4)above.

(c)   Individual hospitals that appeal the quarterly assessment are limited to calculation errors in dividing the annual assessment into four parts. Appeals must be filed within thirty 30 days of receipt of the notice of assessment by OHCA to the hospital. The appeal will proceed in accordance with subsection (4) above.

(d)   If OHCA determines an overpayment of SHOPP payments has been made to an individual hospital, then the hospital may file an appeal within thirty (30) days of the notice of overpayment. Overpayments are deducted from the hospital's payment. The appeal will proceed in accordance with subsection (4) above.

(e)   OHCA recognizes that some individual hospital's claims regarding an inappropriate assessment or overpayment may involve aggregate data. For example an appeal may involve one of the following issues:

(1)   total hospitals in the entire SHOPP pool;

(2)   total hospitals that are exempt from SHOPP;

(3)   total hospitals classified as critical access hospitals;

(4)   total net revenue from all hospitals in the pool;

(5)   the total amount of monies allocated to each pool in the SHOPP; or

(6)   the pro-rata distribution in a pool(s).

(f)   If an individual hospital brings an aggregate appeals claim, there are two (2) elements of proof to be met. The ALJ must determine that the hospital can demonstrate by a preponderance of evidence:

(1)   that data was made available before the hospital submitted the appeal; and

(2)   a specific calculation error has been made statewide that can be shown by the hospital.

(g)   The "Upper Payment Limit" and the "Upper Payment limit Gap" are not appealable in the administrative process.

[Source: Codified --; Added at 29 Ok Reg 187, eff 11-22-11 (emergency); Added at 29 Ok Reg 469, eff 5-11-12]