Due Process and Appeal Rights Guidance

Revised December 2018

Purpose

To provide staff with information and tips on providing appeal rights and due process information to consumers.

Under what circumstances do I provide appeal information?

You must provide appeal rights in writing to all applicants and eligible individuals at certain stages in the VR process, supplementing when necessary via the individual’s preferred mode of communication (including email). You must also provide appeal rights any time a good or service a consumer or applicant requests is denied, reduced, suspended, or terminated by DVR.

For example, if a good or service is requested and denied during a general conversation about services, you must inform the consumer of their appeal rights including the reason for the denial.

Note: Continue to move forward with the case and provide other approved services while the denial and potential appeal occur.

When in a consumer case should I provide appeal information?

Appeal rights must be provided at the following points in every consumer case:

Application
Eligibility or ineligibility determination
OOS category assignment
IPE development and amendment
Case closure

In addition to the above, a consumer or applicant must be provided their appeal rights any time they request the information, including when requested by the individual's legal guardian or designated representative.

Note: Any time one of the above events takes place in a consumer case, provide the consumer with their appeal rights (English, Spanish, Hmong).

What appeal options do applicants and consumers have?

If an applicant or consumer is dissatisfied with any decision made by DVR, we must let the person know they have the right to appeal the decision, with options including informal review, mediation, and impartial hearing.

Definitions

An informal review is a discussion between the consumer and DVR management, typically the supervisor.
Mediation is a meeting or meetings with a neutral third party. Use of the mediation process must be agreed to by both the consumer and DVR, usually the WDA Director.

Note: DVR has the right not to agree to an informal review or mediation.

An impartial hearing is where an Impartial Hearing Officer will hear the facts of the case and make a decision on the issue.

Note: This process does not have to be linear, as consumers can exercise any of the above options at any time.

In addition to these options, consumers may also request a review from the Client Assistance Program (CAP).

What decisions can an applicant or consumer appeal?

Appealable decisions include, but are not limited to:

Ineligibility, OOS placement, or case closure decisions
Decisions regarding services requested prior to IPE development
IPE service decisions

Denial of a service
Timeframe for the service – when a service will start or end
Length of the service
Service provider
Frequency of the service
Payment method
Service setting
Progress measures

What should be included in a denial letter?

Date of the denial
Specific service(s) or finding(s) being denied, reduced, terminated, or suspended
The reason or basis for the denial, reduction, termination, or suspension
Reference to the specific policies or federal regulation citation(s)
Consumer Rights/Appeals statement with correct supervisor's name and phone number

It is recommended that a DVR Supervisor or WDA Director review each denial letter prior to sending to a consumer.

What should happen if a consumer requests a good or service that was previously denied?

If a consumer requests the same good or service that was previously denied, ensure that no circumstances have changed since the original denial and case note the situation, including the original date of the denial letter. Inform the consumer that the request was previously denied, and refer them to the original letter, providing a copy upon request. Additional letters do not need to be sent if circumstances have not changed since the original denial.

If circumstances have changed since the original denial, review the request and consult with your supervisor as appropriate. Examples of changed circumstances include changes to disability or health status, changes in benefits (SSI/SSDI), switching schools (private to public), life changes such as a student moving out of a parent's home, or changes to Long Term Care supports/funding.

Note: For more information on consumer due process rights, see the Consumer Rights and Responsibilities and Due Process sections of the DVR Program and Policy Manual